Treatment of Castration-Resistant Prostate Cancer

Introduction to Treatment Guidelines

The American Urological Association (AUA) considers docetaxel as the standard first-line therapy in metastatic castration-resistant prostate cancer 1
The European Society for Medical Oncology (ESMO) recommends docetaxel using a 3-weekly schedule for symptomatic castration-resistant disease (Level I, A evidence) 2
The National Comprehensive Cancer Network (NCCN) recommends triplet therapies including docetaxel for high-volume metastatic disease in patients fit for chemotherapy 4

Docetaxel with prednisone (75 mg/m² every 3 weeks) is the standard first-line chemotherapy option for patients with castration-resistant prostate cancer who are in good health 1, 2
Docetaxel has demonstrated both survival benefit and palliative benefit in symptomatic disease 1

Novel hormonal agents, such as abiraterone/prednisone and enzalutamide, may be considered before chemotherapy in select patients, particularly those who are asymptomatic or minimally symptomatic 3

LU-177-PSMA-617 is recommended after prior treatment with at least one taxane (docetaxel) and at least one novel androgen receptor axis inhibitor 3
The VISION trial showed improved overall survival (15.3 vs 11.3 months) when LU-177 was used after taxane and androgen receptor inhibitor therapy 3

Approximately 45-48% of patients will have at least a 50% decrease in PSA levels when using docetaxel 5
Early PSA increases (<12 weeks) after starting docetaxel should be ignored when determining progression 5
Delay formal PSA response assessment until 12 weeks (4 cycles of 3-weekly docetaxel) 5
Monitor for neutropenia (occurs in up to 53% with 3-weekly docetaxel) 5
Consider PSMA-based imaging rather than relying solely on PSA measurements 5