Management of Metastatic Prostatic Acinar Adenocarcinoma

First-Line Treatment Options

The American College of Physicians recommends that for patients with metastatic prostatic acinar adenocarcinoma, the standard first-line treatment should be androgen deprivation therapy (ADT) combined with docetaxel, abiraterone, enzalutamide, or apalutamide, as these represent four separate standards of care with proven survival benefits 1
For patients with high-volume disease (HVD) who are candidates for chemotherapy, ADT plus docetaxel should be offered, with a recommended docetaxel regimen of six doses administered at 3-week intervals at 75 mg/m² either alone or with prednisolone 1
ADT plus abiraterone with prednisolone is another standard of care option with proven survival benefits, according to the National Comprehensive Cancer Network 1, 3
ADT plus enzalutamide or ADT plus apalutamide are also standard treatment options for metastatic disease, as recommended by the European Association of Urology 1

Combined Androgen Blockade (CAB) may provide a small survival benefit (1-5% absolute reduction in mortality at 5 years) compared to ADT alone, but with increased toxicity, according to the American Society of Clinical Oncology 2, 3
In a large Japanese retrospective study, CAB showed improved progression-free survival compared to castration monotherapy (11.6 vs 7.1 years), as reported by the Japanese Urological Association 3
For patients with metastatic disease specifically, CAB was associated with a 6-month improvement in overall survival and a 10-month improvement in progression-free survival versus castration alone, according to the European Society for Medical Oncology 3

For metastatic disease, continuous ADT is recommended over intermittent ADT, as stated by the National Institute for Health and Care Excellence 2
While intermittent ADT may be offered to patients with high-risk biochemically recurrent nonmetastatic prostate cancer, it has not been studied in combination with additional cytotoxic or hormonal agents for metastatic disease, according to the American Cancer Society 4, 5
Patients should be informed that intermittent ADT may offer quality-of-life benefits during off-treatment intervals but could potentially impact survival, as recommended by the American Urological Association 6

PSA measurements should be performed every 3-4 weeks initially to assess response to therapy, as recommended by the European Association of Urology 7
Regular imaging follow-up with CT scans and bone scintigraphy should be considered to assess treatment response, according to the National Comprehensive Cancer Network 7

Regular exercise has been shown to reduce fatigue and improve quality of life in men on ADT, as reported by the American College of Sports Medicine 2
Antiresorptive bone therapy has not shown a benefit in the setting of noncastrate bone metastases for skeletal-related event risk reduction, according to the American Society of Clinical Oncology 6