The American Society of Clinical Oncology (ASCO) and Cancer Care Ontario (CCO) have issued a joint clinical practice guideline for the treatment of metastatic castration-resistant prostate cancer (CRPC).1

The new guideline comes in response to the recent development of new agents for the disease and emphasizes quality-of-life considerations in the choice of therapy.

“We have seen unprecedented progress against advanced prostate cancer recently, with six new treatments approved in the last couple of years,” said Ethan Basch, MD, co-chair of the ASCO/CCO expert panel that developed the guideline. “There are a lot of nuances about treatment selection in terms of disease stage and what prior therapies the patient received. We hope this guideline will help doctors and patients make informed treatment decisions.”

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The panel started with the premise that the goal of metastatic CRPC treatment is to provide the best quality of life to the patient for as long as possible. The ASCO/CCO expert panel noted that, over the past decade, several therapies have been approved that offer only modest survival gains but significantly improve quality of life and reduce pain.

 “Including quality-of-life data in the guideline helps people understand how the different treatments will make them feel,” said Andrew Loblaw, MD, co-chair of the expert panel and head of the genitourinary disease site group for CCO. “We also have to be conscious of cost, because it can affect access to treatment and quality of life.”

Key guideline recommendations are:

• Androgen deprivation therapy (pharmaceutical or surgical) should be continued indefinitely.
• Abiraterone/prednisone, enzalutamide, and radium-223 (for men whose cancer has spread predominantly to the bones) have demonstrated survival and quality-of-life benefits and should be offered in addition to androgen deprivation therapy.
• If chemotherapy is being considered, offer docetaxel/prednisone.
• Sipuleucel-T has demonstrated survival benefit but unclear effects on quality of life and may be offered to men with no or minimal symptoms.
• Cabazitaxel/prednisone provides a demonstrated survival benefit and may be offered to men whose disease worsens despite treatment with docetaxel, although its effects on quality of life are unclear.
• Mitoxantrone provides a quality of life benefit but has no demonstrated survival benefits and may be offered.
• Ketoconazole or antiandrogens (bicalutamide, flutamide, nilutamide) may be offered, accompanied by discussion of their limited clinical benefit.
• Bevacizumab, estramustine, and sunitinib should not be offered.
• When any of these agents is offered, a health care provider should discuss the possible clinical benefit and risk of adverse effects with the patient.
• Palliative care should be offered early to all patients during discussion of their treatment options.

The panelists pointed out that some patients misunderstand the goal of treatment of metastatic CRPC to be a cure, and are therefore willing to accept high degrees of toxicity. Communication between health care providers and patients, the panelists noted, is essential to providing the greatest possible benefit.

The panelists found that there is insufficient evidence to recommend the sequence in which treatments should be given.


1. Basch E, Loblaw DA, Oliver TK, et al. Systemic therapy in men with metastatic castration-resistant prostate cancer: American Society of Clinical Oncology and Cancer Care Ontario clinical practice guideline. J Clin Oncol. 2014 Sep 8. [Epub ahead of print] doi: 10.1200/JCO.2013.54.8404.