Prostate Cancer Coverage from Every Angle

Updated ASCO Guideline: First-Line Management of Advanced Prostate Cancer

By: Celeste L. Dixon
Posted: Wednesday, April 28, 2021

An updated American Society for Clinical Oncology (ASCO) evidence-based guideline for the initial treatment of men with noncastrate advanced, recurrent, or metastatic prostate cancer has been published in the Journal of Clinical Oncology. James Talcott, MD, SM, of NantHealth, El Segundo, California, and other panel members provide recommendations for the use of enzalutamide and apalutamide, both second-generation antiandrogen agents, among men with metastatic disease who have had prior docetaxel.

The treatment of men with advanced prostate cancer has changed drastically in the past 13 years. The panel members noted, particularly with the introduction of first- then second-generation antiandrogens, the latter also including abiraterone and darolutamide. For men with high-volume de novo metastatic disease, the current standard of care is docetaxel plus androgen-deprivation therapy (ADT) or abiraterone plus ADT, stated the team.

“Docetaxel, abiraterone, enzalutamide, or apalutamide, each when administered with androgen-deprivation therapy, represent four separate standards of care for noncastrate metastatic prostate cancer,” including in men who have received prior therapies but have not yet experienced disease progression, they continued. Currently, however, “the use of any of these agents in any particular combination or series cannot be recommended.”

Other recommendations or suggestions include the following for men with various prostate cancer scenarios:

  • Noncastrate locally advanced nonmetastatic prostate cancer, following radiotherapy: Consider the combination of ADT plus abiraterone and prednisolone, rather than castration monotherapy.
  • Initial presentation of noncastrate locally advanced nonmetastatic disease in men who have not undergone previous local treatment and are unwilling or unable to undergo radiotherapy: Immediate ADT.
  • High-risk biochemically recurrent nonmetastatic prostate cancer: Intermittent ADT.
  • Low-risk biochemically recurrent nonmetastatic prostate cancer: Consider active surveillance.

The panel members explained that they made the guideline update informed by 4 clinical practice guidelines, 1 clinical practice guidelines endorsement, 19 systematic reviews with or without meta-analyses, 47 phase III randomized controlled trials, 9 cohort studies, and 2 review papers. The update also includes sections about patient/clinician communication, societal health disparities, cost implications, and patients with multiple chronic conditions.

Disclosure: Disclosure information for panel members can be found at

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