Guidelines on the management of recurrent, metastatic, and castration-resistant prostate cancer were published on July 7, 2022 by the Swedish National Prostate Cancer Guidelines Group (SNPCGG), in the Scandinavian Journal of Urology .
Biochemically Recurrent Prostate Cancer
For recurrence after radical prostatectomy in patients with life expectancy of > 10 years, offer early salvage radiotherapy.
For recurrence after primary radiotherapy in patients with a Gleason score 6-7 and slowly rising prostate-specific antigen (PSA) values, watchful waiting until the PSA is over 10 ng/mL is recommended; in those with Gleason score 8–10, higher PSA values, or a PSA doubling time < 6 months, bicalutamide monotherapy is usually recommended as first-line treatment.
Metastatic Prostate Cancer
In all patients with metastatic prostate cancer and a good performance status, offer castration therapy plus either six cycles of docetaxel or continuous treatment with abiraterone/prednisolone, apalutamide, or enzalutamide until radiologic or clinical progression.
For men with primary oligometastatic prostate cancer who are in good general condition with good urinary and bowel function, offer hormonal treatment plus local radiotherapy to the primary tumor; inclusion of regional lymph nodes in the radiotherapy field is optional in cN1 M0 disease.
Castration-resistant Prostate Cancer
Patients with non-metastatic castration-resistant prostate cancer (nmCRPC) who have good performance status, a PSA over 2.0 ng/mL, and a PSA doubling time under 10 months should receive castration therapy plus apalutamide, darolutamide, or enzalutamide. The combined treatment should continue until objective metastatic progression. Patients with nmCRPC who do not fulfil those criteria should be closely monitored and offered castration therapy combined with bicalutamide.
For metastatic castration-resistant prostate cancer (mCRPC), recommended first-line treatment is with docetaxel, enzalutamide, or abiraterone/prednisolone.
For second-line treatment of mCRPC in patients fit for chemotherapy, docetaxel is recommended in cases of previous ARTA (abiraterone, apalutamide, darolutamide, enzalutamide) treatment in the hormone-sensitive setting, and vice versa. For patients who have bone metastasis only and are not suitable for chemotherapy, radium-223 is an alternative.
Options for second- or third-line treatment of mCRPC include cabazitaxel (20 mg/m2) in patients previously treated with docetaxel, and olaparib in patients with BRCA1- or BRCA2-mutated tumors.
Recommended measures for preventing osteoporosis-related fractures and cancer-related skeletal complications include individualized physical exercise for all men on castration treatment and a bisphosphonate or denosumab plus vitamin D and calcium for men at elevated risk. High-dose zoledronic acid or denosumab treatment should be considered for all men with mCRPC and life expectancy over 6 months, with prioritization for those with widespread skeletal metastasis.
Stopping treatment for mCRPC (other than castration treatment) is recommended if two or more of the following criteria are present:
Deterioration of performance status
Increased or new cancer-related symptoms
For more information, please go to Prostate Cancer.
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Cite this: Prostate Cancer Clinical Practice Guidelines (SNPCGG, 2022) - Medscape - Aug 08, 2022.