Table 1.
Areas of consensus (>74%) at PCa consensus forum
| Biochemical recurrence | |
|
| |
| In general, absolute PSA should be used to guide when to initiate ADT after biochemical recurrence following local radical treatment. | 89% |
| Intermittent ADT should generally be used for patients with no documented metastatic disease and PSA-only recurrence following local radical treatment. | 92.6% |
| On average, PSA should be measured every 3–4 months for PSA recurrence after local radical therapy. | 92.6% |
|
| |
| nmCRPC | |
|
| |
| For most patients, a PSADT of <10 months should be used as the threshold to start second-generation AR therapy for patients with nmCRPC. | 78% |
| For most patients, a PSADT of <10 months should be used as the threshold to start second-generation AR therapy for patients with nmCRPC and PSA 10–20 ng/mL. | 88.9% |
| For patients with nmCRPC on conventional imaging and PSADT <10 months, treatment should be initiated with nmCRPC agents, such as apalutamide or enzalutamide. | 96.3% |
| For most patients with nmCRPC on conventional imaging, metastases on PET-based imaging, and PSADT <10 months, treatment with nmCRPC agents, such as apalutamide or enzalutamide, is recommended. | 88.9% |
| Surrogate endpoints likely correlated with OS, such as MFS, provide sufficient evidence for treatment decision-making in nmCRPC. | 100% |
|
| |
| mCSPC | |
|
| |
| For most men presenting with high-volume mCSPC, ADT treatment in the form of LHRH agonist alone (± short course firstgeneration AR antagonist) is recommended. | 81.5% |
| For most patients with de novo, low-volume mCSPC who are not symptomatic from the primary tumor, treatment of the primary tumor is recommended, in addition to systemic therapy. | 74.1% |
| For most patients with de novo, low-volume mCSPC, radiation therapy is the preferred form of treatment of the primary tumor. | 96.3% |
| In men with de novo, high-volume mCSPC who are not symptomatic from the primary tumor, treatment of the primary tumor, in addition to systemic therapy is not recommended. | 78% |
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| |
| Sequencing of treatments across the disease spectrum | |
|
| |
| In patients who receive apalutamide for nmCRPC and subsequently progress to mCRPC, docetaxel is recommended for firstline treatment of mCRPC (with or without stereotactic body radiotherapy). | 81.5% |
| In patients who receive enzalutamide for nmCRPC and subsequently progress to mCRPC, docetaxel is recommended for firstline treatment of mCRPC (with or without stereotactic body radiotherapy). | 85.2% |
| For most asymptomatic or minimally symptomatic men who received docetaxel in the castration-sensitive setting, abiraterone acetate + prednisone or enzalutamide is the preferred first-line treatment option for mCRPC. | 100% |
| For most asymptomatic or minimally symptomatic men who received abiraterone acetate + prednisone in the castrationsensitive setting, docetaxel is the preferred first-line treatment option for mCRPC. | 78% |
| For most symptomatic men who received abiraterone acetate + prednisone in the castration-sensitive setting, docetaxel is the preferred first-line treatment option for mCRPC. | 96.2% |
| For most asymptomatic men who were treated with abiraterone acetate + prednisone or enzalutamide for first-line mCRPC and who had an initial response followed by PSA-only progression (secondary acquired resistance), continuation on current therapy is recommended. | 77.8% |
| For most asymptomatic men who were treated with abiraterone acetate + prednisone or enzalutamide for first-line mCRPC and who had initial response followed by radiologic + PSA progression (secondary acquired resistance), docetaxel is the preferred second-line treatment. | 100% |
| For most men who were treated with abiraterone acetate + prednisone or enzalutamide for first-line mCRPC and who had an initial response followed by progression, docetaxel is the preferred second-line treatment. | 96.3% |
| For most men with mCRPC who are progressing on or after docetaxel for mCRPC, abiraterone acetate + prednisone, or enzalutamide is the preferred second-line treatment for men without prior abiraterone acetate + prednisone or enzalutamide treatment. | 100% |
| In asymptomatic men with mCRPC and PSA-only progression on abiraterone acetate + prednisone, a steroid switch to dexamethasone is recommended. | 85.2% |
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| |
| mCRPC | |
|
| |
| For most asymptomatic or minimally symptomatic men with mCRPC who did not receive docetaxel or abiraterone acetate + prednisone in the castrationsensitive setting, abiraterone acetate + prednisone or enzalutamide is the preferred first-line treatment for mCRPC. | 100% |
| Chemotherapy used after initial ARAT therapy is not felt to restore sensitivity to further ARAT use. | 74.1% |
| In the mCRPC setting, fatigue related to enzalutamide was treated with a dose reduction of enzalutamide. | 88.9% |
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| |
| Genetic testing | |
|
| |
| In men with DNA repair defects (germline or somatic) who progress early on ADT to mCRPC, first-line mCRPC should be treated with standard options. | 78% |
| In men with newly diagnosed metastatic (M1) PCa, genetic counselling and testing is recommended in a minority of selected patients. | 74.1% |
| In men with newly diagnosed metastatic (M1) PCa, genetic counselling and testing is recommended for men with a positive family history for PCa/breast cancer/ovarian cancer.* | 88.9% |
| In men with newly diagnosed metastatic (M1) PCa, genetic counselling and testing is recommended for men with a positive family history for other cancer syndromes (e.g., hereditary breast cancer and ovarian cancer syndrome and/or pancreatic cancer, or Lynch syndrome).* | 74% |
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| |
| Imaging | |
|
| |
| For most men with mCSPC, CT and bone scintigraphy is the recommended imaging modality. | 77.8% |
| For men with CSPC who have received local treatment with curative intent (± salvage radiation therapy), PET-CT (PSMA, choline or FACBC [fluciclovine]) imaging is the modality recommended to diagnose an oligometastatic recurrent state. | 74.1% |
*
Questions belonged to the same question but have been split out in the table for ease of review.
ADT: androgen-deprivation therapy; AR: androgen receptor; ARAT: androgen receptor targeted therapy CRPC: castration-resistant prostate cancer; CSPC: castration-sensitive prostate cancer; CT: computed tomography; LHRH: luteinizing hormone-releasing hormone; m: metastatic; MFS: metastasis-free survival; nm: non-metastatic; PCa: prostate cancer; PET: positron-emission tomography PSA: prostate-specific antigen; PSADT: prostate-specific antigen doubling time; PSMA: prostate-specific membrane antigen.