Editing AUA: Advanced Prostate Cancer (2023) (section)

===== Primary Therapy =====
* '''<span style="color:#ff0000">Patients who have not received prior androgen receptor pathway inhibitors</span>'''

* '''<span style="color:#ff0000">Options (5):</span>'''
**'''<span style="color:#ff0000">First-line: continuous ADT with either (3):</span>'''
**# '''<span style="color:#ff0000">Abiraterone acetate plus prednisone (Grade A)</span>'''
**# '''<span style="color:#ff0000">Enzalutamide (Grade A)</span>'''
**# '''<span style="color:#ff0000">Docetaxel (Grade B)</span>'''
** '''<span style="color:#ff0000">Other options (2):</span>'''
**# '''<span style="color:#ff0000">Sipuleucel-T</span>'''
**#* '''<span style="color:#ff0000">May be offered to patients who are asymptomatic or minimally symptomatic'''
**#** '''Not recommended in symptomatic disease that necessitates opioid use</span>'''
**#* Not associated with objective anti-tumor activity; not appropriate for patients with large tumor burdens, those with visceral disease or with rapidly progressive disease.
**# '''<span style="color:#ff0000">Radium-223</span>'''
**#* '''<span style="color:#ff0000">Should be offered to patients with symptoms from bony metastases from mCRPC and without known visceral disease or lymphadenopathy >3cm.</span>'''
**#* '''<span style="color:#ff0000">MOA: an α-emitting radiopharmaceutical</span>'''
**#** Capable of inducing double strand DNA breaks in cancer cells while minimizing exposure to surrounding marrow.
**#** The use of radium-223 for the treatment of bone metastases relies on the chemical similarity to calcium and the ability of the α-radiation and the short-lived decay products of radium-223 to kill cancer cells.
**#* <span style="color:#ff0000">'''Adverse events include neutropenia and thrombocytopenia'''</span>
**#* '''Targets bone only and is not associated with a PSA decline in a majority of patients; therefore imperative to carefully assess the patient on a monthly basis.'''
**#** Progression in non-bone sites is not infrequent during this 6-month period of treatment.
**#** Given the lack of utility of PSA measurement in this space, the Panel recommends consideration to obtain abdomen/pelvis CT imaging and chest x-ray even in the absence of symptoms prior to cycle 4 (of planned 6 monthly cycles) to assess for occult disease progression.