Page 7 - Castration-resistant prostate cancer (CRPC): CUA/CUOG

Guideline: CRPC management

mCRPC first-line mCRPC second-line mCRPC third-line
CRPC without metastases (if not received in the past) (if not received in the past) (if not received in the past)

Docetaxel
High-risk (PSADT <10 m) Abiraterone
Radium-223
Apalutamide
Enzalutamide (symptomatic and Cabazitaxel
no visceral metastases)
Enzalutamide
Abiraterone or Enzalutamide Radium-223
(if neither received previously)
Not high-risk (PSADT >10 m) Docetaxel
Observation (select cases) Cabazitaxel Clinical trial
(only post-docetaxel)
Clinical trial
Clinical trial

In the presence of bone metastases:
Denosumab or zoledronic acid are recommended to reduce the risk of skeletal
complications
Palliative radiation therapy should be considered in patients with pain

1. The optimal sequence of available options remains unknown. In general, it is felt that changing therapeutic
mechanism of action with each line of therapy is likely to lead to better and longer-lasting response (Expert
opinion).
2. Patients who have had little or no response to hormonal agents OR who progress with minimal change in PSA
OR with significant visceral metastases should be considered for early chemotherapeutic options.
3. Radium-223 is not approved for patients with visceral metastases.
4. Whenever possible, clinical trials should remain the first choice in patients with CRPC.
Fig. 1. Management of castration-resistant prostate cancer (CRPC). m: months; mCRPC: metastatic CRPC; PSADT: prostate-specific antigen doubling time.

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randomized, double-blind, placebo-controlled, phase 3 trial. Lancet Oncol 2019 Feb 6. [Epub ahead of
print]. https://doi.org/10.1016/S1470-2045(18)30860-X Correspondence: Dr. Fred Saad, Centre Hospitalier de l’Université de Montréal, Montreal, QC,
Canada; fredsaad@videotron.ca

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