Management of Metastatic Prostate Cancer

Patient Selection and Treatment Initiation

• For a patient with progressive prostate cancer and bone metastases, the American Urological Association recommends initiating goserelin with antiandrogen coverage for 3-4 weeks to prevent testosterone flare 1
• The National Comprehensive Cancer Network recommends adding enzalutamide 160 mg daily for asymptomatic or minimally symptomatic chemotherapy-naïve metastatic castration-resistant prostate cancer 1, 3

Dosing and Administration

• The European Association of Urology recommends administering goserelin 3.6 mg subcutaneously every 28 days or 10.8 mg every 12 weeks to maintain castrate testosterone levels 1
• The American College of Clinical Oncology recommends enzalutamide 160 mg orally once daily, with a 29% reduction in mortality risk (HR 0.71) and 81% reduction in radiographic progression risk (HR 0.19) in the PREVAIL trial 2

Adverse Effect Management

• The National Comprehensive Cancer Network recommends monitoring for fatigue, hot flushes, diarrhea, hypertension, and seizures, which occur in up to 0.6% of patients, when administering enzalutamide 2

Bone Metastasis Management

• The National Comprehensive Cancer Network recommends adding denosumab 120 mg subcutaneously every 4 weeks or zoledronic acid 4 mg intravenously every 3-4 weeks to prevent skeletal-related events in patients with castration-resistant prostate cancer and bone metastases 4
• The American Urological Association recommends ensuring dental evaluation before initiating bone-targeted therapy and supplementing with calcium and vitamin D to reduce osteonecrosis of the jaw risk 4, 5