The American Urological Association (AUA) developed its new clinical guideline on castration-resistant prostate cancer (CRPC) by creating six index patients to represent the most common clinical scenarios encountered when managing the disease, and establishing the recommendations with these patients in mind.
Citing the significant increase in FDA-approved therapeutic agents for use in men with metastatic CRPC (mCRPC), the AUA’s CRPC panel chair, Michael S. Cookson, MD, of Vanderbilt University in Nashville, Tennessee, and coauthors sought to assist practitioners in the clinical decision-making process. They developed the index patients based on the presence or absence of metastatic disease, the degree of symptoms, the patients’ performance status (as defined by the Eastern Cooperative Oncology Group [ECOG] scale) and prior treatment with docetaxel-based chemotherapy.
The guideline statements are divided into sections that relate to each of the six given types of index patients. For example, for Index Patient 1—a man with asymptomatic, nonmetastatic CRPC—clinicians are advised to recommend observation with continued androgen deprivation. Index Patient 4—a man with symptomatic mCRPC with poor performance status and no prior docetaxel chemotherapy—should not be offered sipuleucel-T therapy, but may be offered treatment with abiraterone plus prednisone, or ketoconazole plus steroid or radionuclide therapy if he is unable or unwilling to receive abiraterone plus prednisone, or docetaxel or mitoxantrone in select cases, specifically when the performance status is directly related to the cancer.
The AUA has also released guidelines covering the following areas:
• Early detection of prostate cancer As reported at www.OncologyNurseAdvisor.com (“New Prostate Cancer Screening Guidelines from AUA Emphasize Targeted Patient Screening,” May 7, 2013), this guideline panel, chaired by H. Ballentine Carter, MD, of the Johns Hopkins Hospital in Baltimore, Maryland, recommends against prostate-specific antigen (PSA) screening in men younger than 40 years; does not recommend routine screening in men aged 40 to 54 years at average risk; and strongly recommends shared decision-making for men aged 55 to 69 years who are considering PSA screening, and proceeding based on a man’s values and preferences. The panel noted that the greatest benefit of screening appears to be for men in this age group.
• Follow-up care for renal cancer Among other recommendations set forth by Sherri Machele Donat, MD, of Memorial Sloan-Kettering Cancer Center, New York, New York, and copanelists, the group advised that patients undergoing follow-up for treated or observed renal masses should undergo a history and physical examination directed at detected signs and symptoms of a metastatic spread or local recurrence. These patients should undergo basic laboratory testing including blood urea nitrogen, creatinine, urine analysis, and estimated glomerular filtration rate, and can undergo other laboratory evaluations as well at the clinician’s discretion.
• Use of radiation after prostatectomy Developed in conjunction with the American Society for Radiation Oncology (ASTRO), these guideline statements include the recommendation that clinicians offer adjuvant radiotherapy (ART) to patients with adverse pathologic findings at prostatectomy because of demonstrated reductions in biochemical recurrence, local recurrence, and clinical progression with adjuvant radiotherapy. This guideline panel was headed by Ian Murchie Thompson, Jr, MD, of the University of Texas Health Science Center at San Antonio (San Antonio, Texas), and Richard Valicenti, MD, MA, of the University of California Davis Comprehensive Cancer Center (Sacramento, California).
All four new guidelines can be found at http://www.auanet.org/education/aua-guidelines.cfm. ONA