Castration sensitive, metastatic
- Patient factors: Is the patient fit?
- Comorbid conditions: Liver disease ( Child Pugh), CVD, DM type 2, Hypertension, hx of seizures
- Gleason 8 or higher, 3 or more bone mets , visceral mets ( need 2 out of 3 for abiraterone)
- If not a candidate for chemo or abiraterone based on the above factors--> enza or apalutamide. Darolutamide is not yet approved in this space.
Young patients with high vol disease start with chemo.
Castration resistant, metastatic
- Prior chemo < 12 months progression--> choose AR blocker based on toxicity profile and patient comorbidities
- Chemo was more than 12 months ago, can consider chemo again if high vol disease and need for quick response.
- First-line can be chemo or AR receptor blocker and switch ( if chemo first, use AR blocker in the second line.)
- Third line--Cabazitaxel is superior.
- PARP inhibitors can be a choice in the third line for BRCA mutation noted.
- Lu -PSMA-617 ( VISION trial) has OS advantage in the third line over SOC treatments.
Nonmetastatic castration sensitive ( biochemical failure) ADT alone, intermittent
Nonmetastatic castration-resistant: salvage radiation, observation or daro/ apalutamide or enza ( if no contraindications)
