4 Before commencing with ADT patients should undergo the following: • a comprehensive history and physical examination that includes falls risk and height 4 measurement prior to initiating ADT • a full baseline cardiometabolic health risk assessment and monitoring for cardiovascular 4 complications whilst receiving ADT • an evaluation of bone mineral density with a 4 DEXA scan • clinicians should obtain baseline calcium and 4 25-hydroxyvitamin D levels at the start of ADT Non-steroidal anti-androgen monotherapy with bicalutamide Bicalutamide is an oral non-steroidal antiandrogen. For patients with M1 disease it has been shown to be less effective in terms of overall survival, clinical progression, and treatment failure than ADT monotherapy and is therefore not 3 recommended as standard of care. Combined androgen blockade with bicalutamide This treatment offers a small survival advantage (< 5%) over ADT monotherapy with increased side effects. It is inferior to the newer combination therapies with ARPIs and should therefore only be 3 used if an ARPI is unavailable. Intermittent versus continuous androgen deprivation therapy This option should only be considered for men who are the best PSA responders and for whom survival is considered secondary to quality of life. Results from the SWOG 9346 trial did not show that intermittent ADT was inferior to continuous ADT in terms of overall survival, but continuous ADT in combination with an ARPI has become the 3 standard of care. Close monitoring of PSA and testosterone levels and possibly imaging is required when using intermittent ADT, especially during off-treatment periods, and patients may need to switch to continuous ADT if there are signs of disease 5 progression. Combination therapy with an androgen receptor pathway inhibitor (ARPI) - New standard of care Combination of ADT together with either abiraterone acetate plus prednisone, enzalutamide or apalutamide improves overall survival, time to radiographic progression, time to 3 pain, and time to chemotherapy. For optimal treatment outcomes this doublet therapy should be implemented on initiation of ADT in men who are t enough and is now regarded as standard of care 3 for the treatment of m(HSPC). Combination therapy with docetaxel for de novo high-volume m(HSPC) For de novo metastatic high-volume hormone sensitive prostate cancer, the use of ADT combined with docetaxel upfront improves survival. However, the overall survival benet is further improved by adding an ARPI to ADT and docetaxel (triple 3 therapy). Combining docetaxel alone with ADT should only be considered if no ARPI is available or all available ARPIs are contraindicated. Usage of docetaxel should be reserved for men who are t enough for 3 chemotherapy. Treatment of the primary tumour in newly diagnosed m(HSPCA) In men with newly diagnosed m(HSPCA) the addition of radiotherapy to the primary tumour increases overall survival in low volume disease 3 only. It is therefore recommended in this situation 3 and not for unselected patient groups. References: 1 Benedict MOA, Steinberg WJ, Claasen F, et al. The prole of Black South African men diagnosed with prostate cancer in the Free State, South Africa. S Afr Fam Pract (2004). 2023 Jan 10;65(1). 2 Le Roux HA, Urry RJ, Sartorius B et al. Prostate Cancer at a regional hospital in South Africa: we are only seeing the tip of the iceberg. South African Journal of surgery. 01 Dec 2015, 53(3 and 4):57-62 3 EAU Guidelines. Edn. presented at the EAU Annual Congress Milan 2023. ISBN 978-94-92671-19-6. Available at: https://uroweb.org/guidelines/prostatecancer/summary-of-changes/2023 4 Kokorovic A, So AI, Serag H, et al. Canadian Urological Association Guideline on androgen deprivation therapy: Adverse events and management strategies. Can Urol Assoc J 2021;15(6).E307-22. http://dx.doi.org/10.5489/cuaj.7355. 5 NCCN Clinical Practice Guidelines in Oncology. Prostate Cancer. Version 4.2023 — September 7, 2023. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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