3 3 Prognostic groups based on PSA levels Based on a large SWOG 9346 cohort, the PSA level after 7 months of ADT was used to create 3 prognostic groups: PSA after 7 months after start of ADT Median survival on ADT monotherapy < 0.2 ng/mL 75 months 0.2 ≤ 4 ng/mL 44 months > 4 ng/mL 13 months Treatments for hormone sensitive metastatic prostate cancer Primary androgen deprivation therapy (ADT) has been the standard of care for over 50 years.3 However, the advent of the androgen receptor pathway inhibitors (ARPIs) and the introduction of chemotherapy earlier in the treatment pathway for high volume disease has improved patient survival and outcomes considerably, and ADT as monotherapy is now no longer considered 3 standard of care. First line Treatment Surgical castration with a bilateral orchiectomy or chemical castration with the use of a LHRH agonist or LHRH antagonist all achieve similar oncological 3 outcomes. For men who present with metastases at the time of diagnosis (synchronous disease) ADT monotherapy is no longer considered standard of care, and wherever possible ADT should be combined with a new androgen receptor pathway inhibitor (ARPI) 3 on initiation of ADT (doublet therapy). The addition of docetaxel to ADT plus an ARPI (triplet therapy), improves overall survival in patients with synchronous high-volume disease. This option should be based on tness for chemotherapy, patient preference, side effects, availability of 3 docetaxel and logistics. Recommended androgen deprivation therapy options Patient prole Preferred Treatment Option Recommended for men who require a rapid reduction of testosterone for complications such as spinal cord compression 3 and/or urinary retention Recommended for men who are unable to access a urology or oncology department or an appropriate healthcare professional at the required intervals for injectable ADT drugs 3 Bilateral orchiectomy Recommended for men with pre-existing cardio-vascular 3 disease or cardiovascular risk factors 3 LHRH antagonists 3 Recommended for all other men 3 LHRH agonists 3 Combine with bicalutamide for 2-4 weeks to prevent testosterone are when necessary Early versus deferred androgen deprivation therapy Early treatment before the onset of symptoms is recommended in the majority of patients with metastatic hormone-sensitive disease, as data indicates that early intervention probably extends time to death for any cause and time to death 3 from prostate cancer (Pca). Deferring treatment for patients with metastatic prostate cancer should only be considered in men who are asymptomatic and who express a strong 3 desire to avoid treatment-related side effects. Men should be counselled about the increased risks of developing symptoms and of dying from cancer by deferring treatment.3 However, this data is based on conventional imaging, and newer imaging technologies may identify patients with oligometastatic disease who could benet from metastases directed therapy in order to delay ADT. Patients who wish to delay the initiation of ADT must 3 be willing to commit to regular follow ups. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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