Editing Castrate-Resistant Prostate Cancer (section)

===== Chemotherapy naïve mCRPC =====

====== Asymptomatic or minimally symptomatic ======
*'''Minimally symptomatic defined as pain that is relieved by acetaminophen or a non-steroidal anti-inflammatory'''
*'''First-line (2):'''
**'''Abiraterone acetate 1000 mg/day plus prednisone 5 mg PO BID OR'''
**'''Enzalutamide 160 mg/day'''
***'''Patients who have had little or no response to hormonal agents OR who progress with minimal change in PSA OR with significant visceral metastases should be considered for early chemotherapeutic options'''
*'''Second-line: Docetaxel (75 mg/m2 every 3 weeks plus prednisone 5 mg PO BID)'''
**The timing of docetaxel therapy in men with evidence of metastases but without symptoms should be individualized based on patients’ clinical status and preferences
** '''Rising PSA only during docetaxel chemotherapy should not be used as the sole criteria for progression; assessment of response should incorporate clinical and radiographic criteria'''

====== Moderate or severe symptoms ======
*'''Docetaxel''' (75 mg/m2 every 3 weeks plus prednisone 5 mg PO BID) '''is recommended'''
* '''Radium-223 every 4 weeks for six cycles is recommended in patients with pain due to bone metastases and who do not have visceral metastases'''
** '''Radium-223 significantly improved overall survival and reduced symptomatic skeletal related events in patients with symptomatic mCRPC who had previously received docetaxel chemotherapy or were deemed unfit for docetaxel'''
* '''Abiraterone''' (1000 mg/day plus prednisone 5 mg twice daily) '''or enzalutamide''' (160mg/day) '''may be considered as first-line therapy in patients who cannot receive or refuse docetaxel'''
** NOTE: The studies in the chemo-naive setting did not include patients with moderate or severe symptoms; however, abiraterone and enzalutamide may be potential therapeutic options in patients who are deemed chemotherapy-ineligible or refuse chemotherapy
* '''Alternative therapies that have not demonstrated improvement in OS but can provide disease control, palliation, and improve quality of life include:'''
** '''Weekly docetaxel plus prednisone'''
** '''Mitoxantrone plus prednisone'''