First brazilian consensus of advanced prostate cancer ...

INT E R NAT IO NA L

BRAZ J UROL

ORIGINAL ARTICLE

First brazilian consensus of advanced prostate cancer: recommendations for clinical practice _______________________________________________ Andre Deeke Sasse, Evanius Garcia Wiermann, Daniel Herchenhorn, Diogo Assed Bastos, Fabio A. Schutz, Fernando Cotait Maluf, George Coura Filho, Igor Alexandre Protzner Morbeck, Juliano J. Cerci, Oren Smaletz, Volney Soares Lima, Ari Adamy Jr., Franz Santos de Campos, Gustavo Franco Carvalhal, Leandro Casemiro Cezar, Marcos Francisco Dall´Oglio, Marcus Vinicius Sadi, Rodolfo Borges dos Reis, Lucas Nogueira

APPENDIX - IBJU | VOL. 43 (3): 407-415, MAY - JUNE, 2017 | DOI: 10.1590/S1677-5538.IBJU.2016.0490

Which of the options below is most recommended as an early androgen deprivation therapy in metastatic prostate cancer?

9%

LHRH agonist

9%

LHRH antagonist

0%

Maximum androgen blockade

0%

Orchiectomy

82%

Other options

APPENDIX - ibju | Vol. 43 (3): 407-415, May - June, 2017 | doi: 10.1590/S1677-5538.IBJU.2016.0490

Is there any indication for the use of cyproterone in the treatment of metastatic prostate cancer?

7%

Yes, in selected cases, in sensitive disease

14%

Yes, in selected cases in castration-resistant disease

79%

No, it is contraindicated


Is the use of combined androgen therapy (GnRH agonist/antagonist + AR antagonists) recommended for treating metastatic prostate cancer?

50%

Yes, for selected cases

21%

Yes, for most patients

29%

No


Is the use of combined androgen therapy (GnRH agonist/antagonist + AR antagonists) recommended for treating metastatic prostate cancer?

60%

Yes, for selected cases

0%

Yes, for most patients

40%

No


What is the recommended serum testosterone concentration for defining castration?

0%

Below 10 ng/dL

7%

Below 32 ng/dL

20%

Below 20 ng/dL

73%

Below 50 ng/dL


Is intermittent ADT, rather than continuous ADT, recommended in patients with radiologically-confirmed metastases and who achieve adequate PSA reduction?

7%

No, it is contraindicated

22%

Yes, in most patients

71%

Yes, only in selected cases


In patients diagnosed with metastatic prostate cancer, is the use of do cetaxel recommended in addition to ADT?

7%

No

20%

Yes, in most patients

73%

Yes, in patients with high volume disease


In patients diagnosed with metastatic prostate cancer, which criteria should be used for indicating docetaxel in addition to ADT? 13%

Visceral disease (lung or liver) and/or some involvement of appendicular skeleton (SWOG)

0%

Diffuse bone metastases (chest, head and/or extremities) and/or visceral disease (lung or liver) (Glass et al 2003)

0% 87%

Visceral disease and/or 4 bone metastases, with at least one out of the pelvis and spinal column (CHAARTED)


What defines the disease as being castration -resistant, considering the patient presents serum testosterone at castration level? 8%

Confirmed PSA progression and/or radiological progression in patient using combined therapy (GnRH analogue/antagonist + add-on classical peripheral antiandrogen)

92%

Confirmed PSA progression and/or radiological progression in patient using ADT


What defines the disease as being castration-resistant, considering the patient presents serum testosterone at castration level? 100%

Confirmed PSA progression and/or radiological progression in patient using ADT

0%

Confirmed PSA progression and/or radiological progression in patient undergoing combined therapy (GnRH analogue/antagonist + add-on classical peripheral antiandrogen)


Should additional treatment be indicated for patients with CRPC in biochemical progression and no metastases by imaging?

47%

Yes

53%

No



33%

Yes

67%

No



31%

Yes

69%

No


In the case of patients with biochemical progression and negative bone scintillography, what other diagnostic method should be indicated? 44%

Full-body MRI

6%

Fluoride PET/CT

12,5% Axial skeleton MRI 12,5% FDG-PET/CT 12,5% Choline PET/CT 12,5% No additional method


In the case of patients with biochemical progression, negative bone scintillography and negative CT-scan, what other diagnostic method should be indicated? 0%

Full-body MRI

0%

Fluoride PET/CT

6%

Axial skeleton MRI

0%

FDG-PET/CT

13%

Choline PET/CT

81%

No additional method


Is metastasis scan indicated in asymptomatic patients with periodic imaging tests?

69%

Yes

31%

No, one should wait until symptoms appear


Should routine metastatic-site biopsy be performed in patients with progressive mCRPC and accessible lesions?

28%

Yes

72%

No


For patients recently diagnosed with oligo-metastatic disease, is local treatment recommended for the primary tumor?

12%

Yes

88%

No


Is re-staging recommended in patients with metastatic CRPC before starting a new treatment line?

6%

No

94%

Yes


Is PSA progression alone, without clinical deterioration or radiological progression, enough to recommend a treatment change?

12%

Yes

88%

No


How should the response to treatment with new hormonal agents be monitored?

0%

PSA surveillance only

100% Through PSA surveillance and regular imaging 0%

Clinical follow-up only


For patients with asymptomatic/mildly symptomatic mCRPC, is it appropriate to opt for vintage endocrine medications when abiraterone or enzalutamide are available?

24%

Yes

76%

No


If available, is the use of abiraterone/enzalutamide recommended as first-line treatment of mCRPC in asymptomatic/mildly symptomatic patients in addition to ADT?

12%

No

88%

Yes


If abiraterone/enzalutamide are available, is the use of docetaxel recommended as firstline treatment of mCRPC in asymptomatic/mildly symptomatic patients in addition to ADT?

47%

Yes

53%

No


If abiraterone/enzalutamide are available, is the use of docetaxel recommended as firstline treatment of mCRPC in asymptomatic/slightly symptomatic patients in addition to ADT?

50%

Yes

50%

No


If available, is the use of abiraterone/enzalutamide recommended as first-line treatment for symptomatic mCRPC patients in addition to ADT?

12%

No

88%

Yes


If abiraterone/enzalutamide are available, is the use of chemotherapy recommended as first-line treatment of mCRPC in symptomatic patients in addition to ADT?

12%

No

88%

Yes


What would be the preferred first-line treatment for mCRPC for PS=0 patients, if all options were available?

0%

Radium 223

12%

Docetaxel

88%

Abiraterone/Enzalutamide


For the new agents acting on the hormonal axis, which should be recommended first in patients with mCRPC?

0%

Enzalutamide first

6%

Abiraterone first

94%


Is the Gleason score important for choosing between abiraterone/enzalutamide or chemotherapy as first-line treatment in mCRPC?

12%

Yes

88%

No


For choosing between abiraterone/enzalutamide or chemotherapy as first-line treatment in mCRPC, should duration of response to first-line ADT be used as a criterion?

33%

No

67%

Yes


For choosing between abiraterone/enzalutamide or chemotherapy as first-line treatment in mCRPC, should duration of response to first-line ADT be used as a criterion?

27%

No

73%

Yes


For choosing between abiraterone/enzalutamide or chemotherapy as first-line treatment in mCRPC, should the presence of visceral metastases be used as a criterion?

38%

No

62%

Yes


For choosing between abiraterone/enzalutamide or chemotherapy as first-line treatment in mCRPC, should the presence of visceral metastases be used as a criterion?

27%

Yes

73%

No


For choosing between abiraterone/enzalutamide or chemotherapy as first-line treatment in mCRPC, should the presence of symptoms be used as a criterion?

29%

Yes

71%

No


is retreatment with docetaxel indicated?

15%

No

85%

Yes, in selected cases


In case of disease progression under treatment with abiraterone/enzalutamide, do you consider the sequential use of the other agent (enzalutamide/abiraterone) to be adequate?

33%

No

67%

Yes


How should the primary resistance to the new agents that act on the androgen receptor axis (abiraterone/enzalutamide) be defined? 50%

Radiographic progression within 3 months of the start of treatment

0%

If there is no significant decline in PSA during treatment

0%

PSA progression within 3 months of the start of treatment

50%

None of the above


How should the primary resistance to the new agents that act on the androgen receptor axis (abiraterone/enzalutamide) be defined? 0%

If there is no significant decline in PSA during treatment

0%

PSA progression within 3 months of the start of treatment

35%

Radiographic progression within 3 months of the start of treatment

65%

None of the above


Are osteolysis inhibitors (zoledronate/denosumab), when available, indicated for patients with mCRPC and bone metastases?

0%

No

100% Yes


Are osteolysis inhibitors recommended for the prevention of secondary bone events in patients with castration-sensitive disease and bone metastases?

40%

Yes

60%

No


Are osteolysis inhibitors recommended for the prevention of secondary bone event in patients with castration-sensitive disease and bone metastases?

0%

Yes

100% No


When should Radium-223 be used in patients with mCRPC and symptomatic bone metastases, but no visceral metastases?

7%

Before docetaxel use

0%

After docetaxel use

93%

In both situations


Is there a role for the use of Radium-223 in patients with asymptomatic mCRPC?

50%

Yes

50%

No


Is there a role for the use of Radium-223 in patients with asymptomatic mCRPC?

6%

Yes

94%

No


Assuming free access to Radium-223, is the use of beta-particle-emitting radiopharmaceuticals (samarium/strontium) still recommended?

6%

Yes

94%

No


Assuming free access to Radium-223, is the use of beta-particle-emitting radiopharmaceuticals (samarium/strontium) still recommended?

18%

Yes

82%

No


Assuming free access to Radium-223, is the use of beta-particle-emitting radiopharmaceuticals (samarium/strontium) still recommended? 0%

Sim

0%

Não


Is there an indication for the use of biomarkers, such as AR-V7, for the therapeutic decision between abiraterone/enzalutamide or chemotherapy?

7%

Yes

93%

No


Is the use of cabazitaxel recommended in patients with mCRPC after a sequence of treatments with abiraterone/enzalutamide and docetaxel?

7%

No

93%

Yes


Should time-to-response to docetaxel influence the choice of the subsequent treatment?

13%

Yes

87%

No


For a patient who responds to docetaxel and has had disease progression less than 3 months after docetaxel discontinuation, the next line of treatment should be:

6%

Cabazitaxel

13%


81%

Both options above are acceptable

0%

Other therapies


For a patient who responds to docetaxel and has had disease progression less than 3 months after docetaxel discontinuation, the next line of treatment should be: 0%


0%

Cabazitaxel

0%

Radium-223

100% The 3 options above are acceptable 0%

Other therapies


For a patient who responds to docetaxel and has had disease progression less than 3 months after docetaxel discontinuation, the next line of treatment should be: 6%

Radium-223

0%


0%

Re-treatment with docetaxel

0%

Cabazitaxel

94%

The 4 options above are acceptable

0%

Other therapies
