Proper Sequencing of Treatment for Castrate Resistant Prostate Cancer

Although androgen deprivation therapy results in clinical and/or disease biochemical remission, disease will ultimately progress from androgen sensitivity to a castration resistant status. Therapeutic options for men with metastatic castration resistant prostate cancer have changed dramatically in the last decade. We review potential sequencing of these therapeutic options based on the currently available published literature.

Since 2010 the Food and Drug Administration has approved 5 new castrate resistant prostate cancer therapies, all with proven survival benefit. These breakthrough therapies and their impact on the disease landscape prompted the AUA in 2013 to establish its first castrate resistant prostate cancer guideline, creating a framework for urologists to better understand their expanded role in the treatment of men with advanced prostate cancer.

Currently, 5 new agents, sipuleucel-T, cabazitaxel, abiraterone, enzalutamide and radium-223 dichloride, have been approved by the Food and Drug Administration to treat castrate resistant prostate cancer on the basis of randomized clinical trials. These approvals, and other anticipated novel therapies, highlight the need for the AUA guidelines to be updated regularly to inform the clinician about this rapidly evolving disease state and the importance of adopting these new therapies.

In less than 3 years multiple new therapeutics have been approved for the treatment of metastatic castration resistant prostate cancer. The mechanisms of action as well as the modes of delivery are largely unique. Recognizing the sequencing order for these new therapies requires an understanding of the published peer reviewed literature as well as clinical judgment and experience. This article provides a review of the literature as well as guidance to assist clinicians who desire to treat metastatic castrate resistant prostate cancer.