Page 1 - Castration-resistant prostate cancer (CRPC): CUA/CUOG

CUA-CUOG GUIDELINE

2019 Canadian Urological Association (CUA)-Canadian Uro Oncology

Group (CUOG) guideline: Management of castration-resistant

prostate cancer (CRPC)

Fred Saad, MD ; Armen Aprikian, MD ; Antonio Finelli, MD ; Neil E. Fleshner, MD ; Martin Gleave, MD ;
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Anil Kapoor, MD ; Tamim Niazi, MD ; Scott A. North, MD ; Frederic Pouliot, MD ; Ricardo A. Rendon, MD ;
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Bobby Shayegan, MD ; Srikala S. Sridhar, MD ; Alan So, MD ; Nawaid Usmani, MD ; Eric Vigneault, MD ;
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Kim N. Chi, MD 13
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1 Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada; McGill University Health Center, Montreal, QC, Canada; Division of Urology, University of Toronto, Toronto, ON, Canada; Department
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of Urological Sciences, University of British Columbia, Vancouver, BC, Canada; Department of Surgery (Urology) and Oncology, McMaster University, Hamilton, ON, Canada; Jewish General Hospital,
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Montreal, QC, Canada; Department of Medical Oncology, University of Alberta, Edmonton, AB, Canada; CHU de Quebec, Université Laval, Quebec City, QC, Canada; Department of Urology, Dalhousie
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University, Halifax, NS, Canada; Division of Medical Oncology, University of Toronto, Toronto, ON, Canada; Department of Oncology, Division of Radiation Oncology, University of Alberta, Edmonton,
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AB, Canada; Department of Radiation Oncology, CHU de Quebec, Université Laval, Quebec City, QC, Canada; BC Cancer Agency, Vancouver, BC, Canada
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Cite as: Can Urol Assoc J 2019;13(10):307-14. http://dx.doi.org/10.5489/cuaj.6136 er metastases are detectable (clinically or by imaging) and
whether the serum testosterone is in the castrate range by
surgical orchidectomy or medical therapy. This defini-
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Published online June 25, 2019 tion creates a clinical-states model, where patients can be
classified. The rising PSA states (castrate and non-castrate)
MEDLINE search of the English language and conference signify that no detectable (measurable or non-measurable)
proceedings were used to produce the present document. disease has ever been found. The clinical metastases states
Wherever Level 1 evidence is lacking, the guideline attempts to (castrate and non-castrate) signify that disease was detect-
provide expert opinion to aid in the management of patients. able at some point in the past, regardless of whether it is
Levels of evidence and grades of recommendation employ detectable now. 3
the International Consultation on Urologic Disease (ICUD)/ Prognosis is associated with several factors that go beyond
WHO modified Oxford Center for Evidence-Based Medicine PSA levels. These include performance status, presence of
grading system. Based on a modified GRADE methodology, visceral metastases, presence of bone pain, extent of dis-
the strength of each recommendation is represented by the ease on bone scan, and serum lactate dehydrogenase and
words STRONG or WEAK. alkaline phosphatase levels. Bone metastases will occur in
90% of men with CRPC and can produce significant morbid-
Introduction ity, including pain, pathological fractures, spinal cord com-
pression, and bone marrow failure. Paraneoplastic effects,
Castration-resistant prostate cancer (CRPC) is defined by dis- including anemia, weight loss, fatigue, hypercoagulability,
ease progression despite castrate levels of testosterone and and increased susceptibility to infection, are also common.
may present as either a continuous rise in serum prostate- CRPC includes patients without metastases or symptoms
specific antigen (PSA) levels, the progression of pre-existing with rising PSA levels despite androgen-deprivation therapy
disease, and/or the appearance of new metastases. (ADT) to patients with metastases and significant debilitation
Advanced prostate cancer has been known under a few due to cancer symptoms.
names over the years, including hormone-resistant prostate can-
cer (HRPC) and androgen-insensitive prostate cancer (AIPC). Management of CRPC
Most recently, the terms castration-resistant prostate cancer or
castration-recurrent prostate cancer were introduced with the ADT and first-generation androgen receptor antagonists
realization that extra-testicular androgen production plays a
significant role in the resistance of prostate cancer cells to medi- Because the androgen receptor remains active in most
cal or surgical castration therapy. 1 patients who have developed castration-resistant disease,
In their second publication, the Prostate Cancer Working it is recommended that ADT be continued for the remain-
Group defined CRPC as a continuum on the basis of wheth- der of a patient’s life (Level 3, Strong recommendation).
CUAJ • October 2019 • Volume 13, Issue 10 307
© 2019 Canadian Urological Association