Page 1 - mCSPC Card 07
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Management of Metastatic
            Castration-Naïve and Castration-Sensitive
                                Prostate Cancer


          Newly Diagnosed mCSPC Management Algorithm


                                  Newly diagnosed mCSPC


                                       Initiate ADT 1


                  Staging and determine prognosis  based on high-volume/high-risk criteria
                                         2

                   Consider referral to specialized tertiary centre for multidisciplinary care

           High-volume/high-risk disease  mCSPC, not segmented by  Low-volume/low-risk disease
                             3
           •  High-volume (CHAARTED) ;   disease volume nor risk  •  No high-volume criteria 3
              ≥1 criterion: visceral                      •  None or one high-risk
             metastases, ≥4 bone                            criterion 4
              lesions with ≥1 beyond the
              vertebral bodies and pelvis
           •  High-risk (LATITUDE) ;
                          4
              ≥2 criterion: visceral
             metastases, ≥3 bone
              lesions, Gleason score ≥8

                                                            Docetaxel  [L2WR] or
                                                                   3,6
             Abiraterone  [L1SR] or                            EBRT  [L2SR] or
                      4-6
                                                                  9
              Docetaxel  [L1SR] or                          Abiraterone 3,5,6  [L3WR] or
                     3,6
              Apalutamide  [L1SR] or  Apalutamide  [L1SR] or  Apalutamide  [L1SR] or
                                                                     7
                      7
                                             7
                       8
              Enzalutamide  [L1SR]   Enzalutamide  [L1SR]    Enzalutamide  [L1SR]
                                                                      8
                                              8
               Clinical, radiological,    Clinical, radiological,    Clinical, radiological,
               or PSA progression 10  or PSA progression 10  or PSA progression 10
            Begin treatment for mCRPC  Begin treatment for mCRPC  Begin treatment for mCRPC
      Adapted from So AI, et al. Can Urol Assoc J. 2020;14(2)17-23.
      1.  Ensure castrate levels of testosterone.
      2.  Consider determination of alkaline phosphatase levels as prognostic factor (Gravis et al. Eur Urol 2015;68:196-204).
      3.  Patients identified according to CHAARTED criteria (Sweeney et al. N Engl J Med 2015;373:737-46).
      4.  Patients identified according to LATITUDE criteria (Fizazi et al. N Engl J Med 2017;377:352-60).
      5.  Abiraterone plus prednisone 5 mg daily.
      6.  Patients who are ineligible for either docetaxel or abiraterone for medical reasons or patient preference should be offered alternate agent, if appropriate.
      7.  TITAN trial: apalutamide improved rPFS and OS (all-comers); benefit was maintained regardless of volume of disease
      8.  ARCHES trial: enzalutamide improved rPFS (all-comers); benefit was maintained regardless of volume of disease
      9.  HORRAD and STAMPEDE trials; STAMPEDE patients classified per CHAARTED criteria
      10. PSA progression as defined by PCWG2 criteria.
      [L1SR] = Level 1, strong recommendation; [L2SR] = Level 2, strong recommendation; [L2WR] = Level 2, weak recommendation; [L3WR] = Level 3,
      weak recommendation.
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