Management of Metastatic Prostate Cancer

Assessment and Diagnosis

The American College of Radiology suggests that a patient with rising PSA levels and CT findings showing disseminated metastatic disease should undergo a complete staging workup, including contrast-enhanced CT of the abdomen/pelvis and bone scan to evaluate for osseous metastases 1, 2, 3, 4
The patient's presentation, with extensive peritoneal nodularity, prostatomegaly, liver lesions, and porta hepatis mass, is consistent with metastatic prostate cancer, and biopsy of an accessible metastatic site is recommended to confirm the diagnosis 5, 3

The American Urological Association recommends initiating systemic therapy with androgen deprivation therapy (ADT) plus a novel hormonal agent for patients with metastatic hormone-sensitive prostate cancer, with consideration for additional imaging to further characterize the extent of disease 6, 7
For metastatic castration-resistant prostate cancer, the treatment approach should be based on prior treatments and response, with consideration for adding abiraterone acetate with prednisone, enzalutamide, or docetaxel chemotherapy 6, 8
The American College of Radiology suggests that patients with symptomatic mCRPC and good performance status should be considered for radium-223 if bone metastases are predominant and no visceral disease 8

The American Urological Association recommends incorporating pain management and addressing other symptoms into the treatment plan, with a focus on quality of life and symptom management for patients with poor performance status 6, 8
The National Comprehensive Cancer Network suggests that treatment sequencing should be considered based on prior treatments and response, with sequential use of alternative agents as needed 9

Baseline testosterone level should be determined to assess castration status, according to the Journal of Clinical Oncology 10

Monitoring should focus on clinical and radiographic progression rather than PSA alone, as PSA changes do not necessarily correlate with clinical benefit, as stated in the Journal of Clinical Oncology 11