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Treatment consideratons in mCSPC, nmCRPC, mCRPC
Treatment Considerations in mCSPC, nmCRPC, mCRPC

• Maintain ADT throughout treatment continuum for advanced disease
• Many patients are eligible for systemic therapy beyond ADT
• Referral to a specialized centre for GU multidisciplinary consult or urologic oncologist is recommended
• For patients who are candidates for systemic therapy (with ADT), perform a thorough baseline assessment
• Choice of treatment should consider the following factors:
– Patient characteristics (eg, life expectancy, age, comorbidities)
– Tumour characteristics (eg, disease burden)
– Evidence of neuroendocrine differentiation
– Presence of germline or tumour HRR mutation(s)
– Patient preferences and expectations
– Quality of life
• Consider bone and cardiovascular health throughout treatment
• Treatment sequencing should give preference to agents with a different mechanism of action from the prior line
• Consider palliative radiation therapy in patients with pain
• Because advanced disease remains non-curative, encourage patients to participate in clinical trials
mCSPC

• Patients with de novo metastatic disease may have a shorter duration of hormone sensitivity and worse survival compared with
patients with primary progressive metastatic disease
• Chemotherapy may be better suited for patients with: high-volume metastatic disease and discordant PSA indicating potential
neuroendocrine differentiation; or high-volume visceral metastasis (particularly liver metastases)

Bone health – Refer to CUA Guideline on ADT: Adverse events and management strategies. (Kokorovic et al. Can Urol Assoc J. 2021)

• Osteoporosis prevention in men on ADT
– Conduct a comprehensive history, physical examination, and assess for fracture risk
– Lifestyle modifications per CUA guideline (smoking and alcohol cessation, exercise)
– Supplementation: Vit D 800-2000 IU daily, Calcium 1200 mg total intake daily
– If high risk for fractures: alendronate 10 mg PO qd or 70 mg PO q1w; or risedronate 5 mg PO qd or 35 mg PO q1w or
150 mg PO q1mo; OR zoledronic acid 5 mg IV q1yr; or denosumab 60 mg SC q6mo

• Prevention of disease-related skeletal-related events (SREs) in men with mCRPC and bone metastases
– Supplementation: Vit D 800-2000 IU daily, Calcium 1200 mg total intake daily
– Denosumab 120 mg SC q4w OR zoledronic acid 4 mg IV q4w [L1sr]; do not use zoledronic acid if creatinine clearance <30 mL/min
– Optimal duration of treatment is undefined; risk of osteonecrosis of the jaw appears to be related to time on therapy,
caution with use >2 years [L3wr]
– Denosumab or zoledronic acid should always be used when using radium-223 (L1sr)