In recent years, a number of new drugs have emerged in the treatment of prostate cancer, particularly some immunotherapeutic agents that have come to market, offering cancer patients hope for a cure. In response, the National Comprehensive Cancer Network (NCCN) has continuously updated its prostate cancer guidelines to promote more standardized use of these new therapies in clinical practice.
The latest version of the NCCN guidelines recommend a total of two chemotherapy regimens and two immunotherapies for patients with stage M1 castration resistant prostate cancer (CRPC):
- Chemotherapy
- Docetaxel + steroids
- Cabazitaxel + steroids
- Immunotherapy
- Sipuleucel-T
- Pimozumab
Pimozumab
- Pembrolizumab (trade name Keytruda, also known as pablizumab) is a programmed death-1 (PD-1) inhibitor that was approved in the United States for melanoma, lung cancer, head and neck cancer, lymphoma, bladder cancer, colorectal cancer, and other for a variety of cancers.
- The guidelines recommend pembrolumab only as a follow-up systemic therapy for patients with stage M1 CRPC who have experienced disease progression after receiving at least one systemic therapy.
Sipuleucel-T
- The guidelines recommend that Sipuleucel-T be considered for patients with CRPC who are
- Good physical status (ECOG 0-1)
- Estimated life expectancy>6 months
- No liver metastases
- No symptoms or mild symptoms
- A phase 3 clinical trial showed that patients in the Sipuleucel-T treatment group had an average survival extension of about 4 months compared to the control group, resulting in a 22% reduction in the risk of death.
- Sipuleucel-T was well tolerated, with common complications including chills, fever, and headache.
Docetaxel
- Guidelines recommend docetaxel + steroid therapy every 3 weeks as the preferred first-line chemotherapy regimen.
- In addition, the guidelines also recommend for situations where docetaxel is not appropriate or where docetaxel therapy has failed.
- Patients who are not suitable for docetaxel therapy or are docetaxel intolerant should consider cabazitaxel + steroid therapy.
- Radium-223 was studied in symptomatic patients who were not candidates for docetaxel-based regimens and was shown to improve overall survival.
- The study found that abiraterone and enzalutamide prolonged survival in patients who developed disease progression after docetaxel treatment.
Carbataxel
- As mentioned above, the guidelines recommend that patients who are unsuitable for or intolerant to docetaxel therapy should consider cabazitaxel + steroid therapy.
- Cabazitaxel 20 mg/m² every 3 weeks + prednisone and/or growth factor support has become the standard treatment regimen after docetaxel therapy.
- Cabazitaxel has a lower incidence of peripheral neuropathy compared with docetaxel and is appropriate for patients with preexisting mild peripheral neuropathy. However, current data do not support the superior efficacy of cabazitaxel over docetaxel.
In addition, denosumab and zoledronic acid have been shown to prevent disease-related skeletal complications (fractures, spinal cord compression, or bone requiring surgery or radiation therapy) in patients with desmoresistant prostate cancer with bone metastases.
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