In recent years, new therapeutic options have brought improvements in the treatment of metastatic, castration-resistant prostate cancer. Targeted Hormone Therapy (THT) represents a novel therapeutic component for which recent studies have shown a maximum benefit in the time between failure of androgen deprivation therapy (patient is metastatic and still pain-free) and prior to chemotherapy. Prostate cancer experts of the Austrian Society of Urology and Andrology (ÖGU), the Working Group for Urologic Oncology as part of the ÖGU, and the Professional Association of Austrian Urologists (BvU) have developed recommendations for the treatment of patients with asymptomatic or mildly symptomatic metastatic, castration-resistant prostate cancer. The definition of failure of classical hormonal therapy has been based on the guidelines of the German Society of Urology (Deutsche Gesellschaft für Urologie, DGU) and the European Association of Urology (EAU). Criteria for the initiation of treatment with hormonal or chemotherapy include:
Castration resistance with increase of prostate-specific antigen (PSA)
Evidence of metastases in imaging
No or mild symptoms
Quality of Life Index of the Eastern Cooperative Oncology Group (ECOG) 0-1 (ECOG 2 requires individualized decision) .
Treatment should only be initiated when all of these four criteria are applicable, with the age of the patient being no exclusion criterion. First-line therapies for these patients include abiraterone, enzalutamide, and docetaxel as well as radium-223. The manuscript refers only to treatment regimens available in Austria.
Selection of the initial treatment option—starting with THT or chemotherapy—should be determined based on the individual patient characteristics. When using abiraterone or enzalutamide, re-staging within 3–6 months is recommended.