CUA 2019 CRPC GL

Question 1

what is mCRPC?

Answer 1

rising PSA despite castrate testosterone, progression of disease, appearance of new metastasis

Question 2

What are predictors of prognosis in mCRPC?

Answer 2

performance status, presence of visceral metastasis, presence of bone pain, extent of disease on bone scan, LDH, ALP levels

Question 3

The first generation androgen receptor antagonists have any survival benefit in CRPC?

Answer 3

NO

Question 4

What is high risk nmCRPC?

Answer 4

PSA DT<10 months, if estiamted life expectancy> 5 years treat with apalutamide or enzalutamide, darolutamide

Question 5

What was the primary endpoint in enza and apa study in nmCRPC?

Answer 5

MFS (40.5 month vs 16.5 months for APA)

MFS 36.6 vs 14 months for Enza

Question 6

How often should patients with nmCRPC have imaging?

Answer 6

PSADT<10months or PSA>20: CT and bone scan Q 3-6 months

PSADT>10 months: CT and bone scan Q6-12 months

Question 7

How does abiraterone work?

Answer 7

potent inhibitor of CYP-17 a critical enzyme in androgen biosynthesis

Question 8

What is recommended for asymptomatic or minimally symptomatic patients with mCRPC who are chemo naïve?

Answer 8

Abiraterone + prednisone or Enzalutamide

Spluecel T

Question 9

Which patients are considered asymptomatic or minimally symptomatic?

Answer 9

Ones only requiring acetaminophen or NSAIDs

Question 10

What is recommended for patients progressing on or after docetaxel based chemo?

Answer 10

Abiraterone + Pred or Enzalutamide
Cabazitaxel
Radium 223

Question 11

what chemotherapeutic options are available for MCRPC?

Answer 11

docetaxel, cabazitaxel(2nd line- upon progression on docetaxel)
alternatively: mitoxantrone, docetaxel q weekly instead of q 3 weeks

Question 12

What if you have someone whose PSA is not progressing on ADT but is having worsening symptoms and mets or dont respond to ADT at all? next step and management

Answer 12

Biopsy a lesion to rule out NE differentiation

Treat with Cisplatin etoposide, carboplatin/etoposide

Question 13

Which bone targeted therapy is associated with improved OS?

Answer 13

RADIUM 223

Question 14

Who should get Radium 223(alpharadin)?

Answer 14

patients with painful bony mets with no visceral mets. 6 cycles Q 4 weeks– NOTE: PSA measurements meaningless on radium, check ALP

Question 15

who was excluded from radium studies

Answer 15

patietns with visceral mets, LN mets>3cm

Question 16

Should you combine radium with abi/pred?

Answer 16

No should not be combined, no benefit.

Question 17

Should you use a bone supporting agent when using radium?

Answer 17

yes, denosumab or zoledronic acid

Question 18

are there any bone supportive agents recommended for patients with CRPC and bone metastasis?

Answer 18

Yes, denosumab or zoledronic acid to reduce SRE

Question 19

What is Zoledronic acid?

Answer 19

third generation nitrogen containing bisphosphanate

Question 20

Is there a contraindication to giving zoledronic acid?

Answer 20

eGFR<30

Question 21

What is Denosumab?

Answer 21

Humanized monoclonal antibody against RANK ligand.

Question 22

in mCRPC is denosumab superior to zoledronic acid in preventing time to SREs?

Answer 22

YES

Question 23

Why should caution be taken with using bone targeted agents beyond 2 years?

Answer 23

increased risk of osteonecrosis of the jaw