Page 1 - Metastatic castration-naive and castration-sensitive prostate cancer: CUA/CUOG
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CUA gUideline







         Canadian Urological Association-Canadian Urologic Oncology Group

         guideline on metastatic castration-naive and castration-sensitive


         prostate cancer


         Alan I. So, MD ; Kim N. Chi, MD ; Brita Danielson, MD ; Neil E. Fleshner, MD ; Anil Kapoor, MD ;
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         Tamim Niazi, MD ; Frederic Pouliot, MD ; Ricardo A. Rendon, MD ; Bobby Shayegan, MD ;
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         Srikala Sridhar, MD ; Eric Vigneault, MD ; Fred Saad, MD
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         1 Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada;  Department of Medicine, University of British Columbia, Vancouver, BC, Canada;  Department of Oncology, Division
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         of Radiation Oncology, University of Alberta, Edmonton, AB, Canada;  Division of Urology, University of Toronto, Toronto, ON, Canada; Division of Urology, McMaster University, Hamilton, ON, Canada;
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         6 Department of Oncology, Division of Radiation Oncology, McGill University, Montreal QC, Canada;  Division of Urology, Department of Surgery, Université Laval, Quebec City, QC, Canada;  Department of
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         Urology, Dalhousie University, Halifax, NS, Canada;  Division of Hematology and Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada;
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         10 Department of Radiation Oncology, CHUQ, Université Laval, Quebec City, QC, Canada;  Department of Surgery, Université de Montréal, Montreal, QC, Canada
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         Cite as: Can Urol Assoc J 2020;14(2):17-23. http://dx.doi.org/10.5489/cuaj.6384  Methods
                                                               EmBASE and Medline databases were accessed to identify
         Published online December 5, 2019                     all relevant articles focused on mCNPC or mCSPC between
                                                               January 2000 and August 2019 with the following key-word
                                                               strategy: “prostate cancer,” “hormone sensitive,” “castra-
         Introduction                                          tion naïve,” “castration sensitive,” “androgen deprivation,”
                                                               “chemotherapy,” “androgen receptor-axis targeted thera-
         Metastatic prostate cancer remains an incurable disease. In   py,” and “metastatic.” An expert panel comprised of urolo-
         Canada, approximately 8% of men with prostate cancer are   gists, medical oncologists, and radiation oncologists with
         diagnosed de novo with metastatic disease and, in 2018,   significant experience managing mCNPC/mCSPC was used
         roughly 1200 men were diagnosed with de novo metastat-  to develop the recommendations. Guidelines were devel-
         ic prostate cancer (PC).  The mainstay of treatment for de   oped by consensus among the panel. Levels of evidence
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         novo metastatic PC is androgen-deprivation therapy (ADT),   and grades of recommendation employ the WHO modi-
         which is initially effective in almost all patients. Progression   fied Oxford Center for Evidence-Based Medicine grading
         is inevitable, however, heralded by a rise in prostate-specific   system.  Based on a modified GRADE methodology, the
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         antigen (PSA), increasing disease burden, and/or worsening   strength of each recommendation is represented by the
         symptoms — a disease state called metastatic castration-  words “Strong” or “Weak.”  Wherever Level 1 evidence is
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         resistant prostate cancer (mCRPC).                    lacking, the guideline attempts to provide expert opinion
           Men with de novo metastatic PC have a poor prognosis,   to aid in the management of patients.
         with an estimated median overall survival (OS) of approxi-
         mately 3–4 years.  This has only improved slightly, even with   Indications for staging in PC
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         the advent of improved management of mCRPC.  Compared
         to PC that develops metastases after diagnosis, de novo meta-  For newly diagnosed PC, staging with computed tomogra-
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         static PC has been shown to have a worse prognosis.  Recent   phy (CT) scan of the abdomen and pelvis and bone scan
         practice-changing trials have shed light on new directions   (99mTc-MDP) should be performed for men with any high
         to improve survival in men with metastatic castration-naive/  risk features: PSA>20 ng/mL, Gleason score >7, clinical stage
         castration-sensitive PC (mCNPC/mCSPC), and include both   T3 or greater (Level of evidence 3, Strong recommendation).
         systemic therapies and treatment of the primary cancer.
           The Canadian Urologic Oncology Group (CUOG), in col-  Conventional imaging to stage PC includes bone scin-
         laboration with the Canadian Urological Association (CUA)   tigraphy using technetium-99mmethylene diphosphonate
         sought to provide management guidelines to optimize the   (99mTc-MDP) to assess for bone metastases and abdomi-
         treatment of mCNPC/mCSPC patients.                    nopelvic CT imaging to assess for lymphadenopathy and
                                                               visceral metastases. In patients with high-risk disease, CT

                                                   CUAJ • February 2020 • Volume 14, Issue 2                    17
                                                    © 2020 Canadian Urological Association
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