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J Clin Oncol. 2014 Oct 20;32(30):3436-48. doi: 10.1200/JCO.2013.54.8404. Epub 2014 Sep 8.

Systemic therapy in men with metastatic castration-resistant prostate cancer:American Society of Clinical Oncology and Cancer Care Ontario clinical practice guideline.

Author information

Ethan Basch, Ronald C. Chen, and Stacie B. Dusetzina, University of North Carolina, Chapel Hill; Derek Raghavan, Carolinas Health Care/Levine Cancer Institute, Charlotte, NC; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre; Ted Wootton, Patient Representatives, Toronto; Sebastian Hotte and Cindy Walker-Dilks, McMaster University; Cindy Walker-Dilks, Cancer Care Ontario, Hamilton; Eric Winquist, London Health Sciences Centre, London, Ontario; Fred Saad, University of Montreal, Montreal, Quebec, Canada; Thomas K. Oliver and R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Michael Carducci, Johns Hopkins University, Baltimore, MD; James N. Frame, Charleston Area Medical Center Health Systems, Charleston, WV; Kristina Garrels, Private Practice, Fargo, ND; Michael W. Kattan, Cleveland Clinic, Cleveland, OH; Mary-Ellen Taplin, Dana-Farber Cancer Institute, Boston, MA; James Williams, Pennsylvania Prostate Cancer Coalition, Camp Hill, PA; Charles L. Bennett, South Carolina College of Pharmacy, Columbia, SC; and Katherine S. Virgo, Emory University, Atlanta, GA.



To provide treatment recommendations for men with metastatic castration-resistant prostate cancer (CRPC).


The American Society of Clinical Oncology and Cancer Care Ontario convened an expert panel to develop evidence-based recommendations informed by a systematic review of the literature.


When added to androgen deprivation, therapies demonstrating improved survival, improved quality of life (QOL), and favorable benefit-harm balance include abiraterone acetate/prednisone, enzalutamide, and radium-223 ((223)Ra; for men with predominantly bone metastases). Improved survival and QOL with moderate toxicity risk are associated with docetaxel/prednisone. For asymptomatic/minimally symptomatic men, improved survival with unclear QOL impact and low toxicity are associated with sipuleucel-T. For men who previously received docetaxel, improved survival, unclear QOL impact, and moderate to high toxicity risk are associated with cabazitaxel/prednisone. Modest QOL benefit (without survival benefit) and high toxicity risk are associated with mitoxantrone/prednisone after docetaxel. No benefit and excess toxicity are observed with bevacizumab, estramustine, and sunitinib.


Continue androgen deprivation (pharmaceutical or surgical) indefinitely. Abiraterone acetate/prednisone, enzalutamide, or (223)Ra should be offered; docetaxel/prednisone should also be offered, accompanied by discussion of toxicity risk. Sipuleucel-T may be offered to asymptomatic/minimally symptomatic men. For men who have experienced progression with docetaxel, cabazitaxel may be offered, accompanied by discussion of toxicity risk. Mitoxantrone may be offered, accompanied by discussion of limited clinical benefit and toxicity risk. Ketoconazole or antiandrogens (eg, bicalutamide, flutamide, nilutamide) may be offered, accompanied by discussion of limited known clinical benefit. Bevacizumab, estramustine, and sunitinib should not be offered. There is insufficient evidence to evaluate optimal sequences or combinations of therapies. Palliative care should be offered to all patients.

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