Secondary hormonal manipulation in castration resistant prostate cancer

Castration resistant prostate cancer (CRPC) is the single common pathway to prostate cancer death. For men with symptomatic metastatic disease, docetaxel chemotherapy remains a standard of care. However, blood prostatic-specific antigen (PSA) testing allows the identification of CRPC before clinical metastases or symptoms occur, providing a long diagnostic lead time in many patients. The use of secondary hormonal manipulations (SHMs) in men not candidates for immediate chemotherapy is reviewed.

PubMed was searched for randomized clinical trials, systematic reviews or clinical practice guidelines addressing SHMs in CRPC.

A recent systematic review and practice guideline was identified, and used as the evidence base for this review along with reports from randomized trials over the past year.

The goals of therapy with SHMs should be discussed with patients and their preferences considered. In men without clinical evidence of metastases, gonadal androgen suppression should be maintained and generally patients should be observed. There is no clear evidence that SHMs are of benefit in these patients. Abiraterone plus prednisone is of proven benefit in men with CRPC metastases who are without significant symptoms prior to chemotherapy. Based on emerging data, enzalutamide may be of similar benefit. Use of other SHMs should be based on patient preference and consideration of possible adverse effects; with the exception of low dose prednisone, there is little evidence of benefit supporting their use. For patients accepting these uncertainties, a trial of nonsteroidal antiandrogen may be considered as an adjunct to observation, followed by low dose corticosteroid with immediate or delayed addition of abiraterone (in men with metastases) as a reasonable next step.