-
Leuprolide (Lupron Depo, Eligard)
- LHRH agonist
- initial tumor flare (use an anti-androgen)
- sleep disorders, sweating, hot flashes, pain, HA, QT prolongation (men in menopause)
-
Goserelin (Zoladex) subQ implant
- GnRH agonist
- initial increase in LH and FSH
- chronic admin. results in sustained suppression of pituitary gonadotropins
- sleep disorders, sweating, hot flashes
-
Triptorelin (Trelstar) IM
- GnRH agonist
- sleep disorders, sweating, hot flashes
-
Degarelix (Firmagon) SubQ
- GnRH antagonist -- binds reversibly to pituitary GnRH receptors, reducing release
- hot flashes, increase in transaminases, inj site rxns
- No initial flare, no anti-androgen needed
-
Flutamide (Eulexin)
- Anti-androgen -- inhibit androgen uptake and/or inhibits binding of androgens
- CYP 3A4 or 1A2
- hot flashes, CV disease, gynecomastia
- Given TID -- comliance issues
-
Bicalutamide (Casodex)
- Anti-androgen -- androgen receptor inhibitor, specifically a competitive inhibitor for the binding of dihydrotestosterone and testosterone
- gynecomastia, hot flashes, CV disease
- PO Daily
-
Nilutamide (Nilandron)
- BBW for hepatic failure
- disulfiram rxn, interstitial pneumonitis, visual adaptation delays
- hot flashes, gynecomastia, CV problems
- PO Daily
-
Alternative Treatment options
- Ketoconazole -- hydrocortisone replacement
- Secondary hormone manipulation
- Anti-androgen withdrawal
- Aminoglutethimide
-
Docetaxel
- Microtubule inhibitor
- Peripheral neuropathy, myelosuppression, alopecia, inj. site rxn
-
Cabazitaxel (Jevtana)
- Microtubule inhibitor
- neutropenia, peripheral neuropathy, hypersensitivity rxn, GI syptoms (emesis)
- Hormone refractory prostate cancer, after failure of Docetaxel regimine
-
Sipuleucel-T (Provenge)
- autologus CD54+ cells, administer doses in 2 week intervals for 3 doses (expensive)
- premedicate with APAP and Benadryl
- metastatic hormone refractory prostate cancer with minimal/no symptoms
-
Enzalutamide (Xtandi)
- Anti-androgen -- pure androgen receptor signaling inhibitor, no known agonistic properties
- Seizures, gynecomastia, hot flashes, CV disease
- Metastatic, castrate resistant prostate cancer previously treated with Docetaxel
- DDI: 2C8, 3A4
-
Abiraterone (Zytiga)
- Selectively and irreversibly inhibits CYP17, inhibits formation of testosterone precursors DHEA and androstenedione
- Metastatic, CRPC, who have failed docetaxel
- Food increases AUC 10 fold
-
Very low risk for recurrence
- life expectancy <20 years = active surveillance
- life expectancy >20 years = active surveillance, radiotherapy, or radical prostatectomy
-
Low risk for recurrence
- LRPC and life expectancy <10 years = active surrveillance
- LRPC and life expectancy > 10 years = radical prostatectomy +/- PLND
- life expectancy >15 years = RT, surgery, brachytherapy
-
Low risk for recurrence criteria
- Tumors T1 to T2a
- Gleason score <= 6
- Serum PSA <= 10 ng/ml
-
Intermediate risk for recurrence criteria
- Any T2b-T2c
- Gleason score of 7
- PSA of 10-20 ng/ml
- Any patient with 1 or more is High Risk
-
Intermediate risk for recurrence
- IRR + < 10 years life expectancy = AS or RT may also add ADT for 4-6 months
- IRR + > 10 years life expectancy = RT, radical prostatectomy + PLND, 4-6 months of ADT; can use brachytherapy but not alone
-
High risk for recurrence criteria
- T3a
- Gleason score 8-10
- PSA >20 ng/ml
- Any patient with 1 or more is Very Hign Risk
-
High risk for recurrence
- HRR should be treated unless life expectancy is <5 years
- HRR treatment with RT + ADT (2-3 years)
- RT + Brachytherapy + ADT (Primary tx option)
- Radical prostatecotmy + PLND
- NO ADT alone
-
Very High risk for recurrence
- T3b to T4
- COmbo RT + Long term ADT
- Combo Rt + brachytherapy +/- ADT
- Radical prostatectomy + PLND
- ADT
-
Metastatic Disease
- ADT
- RT + neoadjuvant/concomitant/adjuvant ADT (2-3 years)
- ADT is recommened for all pts with M1 disease
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