Management algorithms for prostate-specific antigen progression in prostate cancer: Biochemical recurrence after definitive therapy and progression to non-metastatic castrate-resistant prostate cancer

INTRODUCTION: Current prostate cancer (PCa) guidelines primarily focus on localized or metastatic PCa. A multidisciplinary genitourinary oncology panel determined that additional guidance focusing on monitoring and management of biochemical recurrence (BCR) following radical therapy and non-metastatic castration-resistant prostate cancer (nmCRPC) was warranted. METHODS: The most up-to-date national and international guidelines, consensus statements, and emerging phase 3 trials were identified and used to inform development of algorithms by a multidisciplinary genitourinary oncology panel outlining optimal monitoring and treatment for patients with non-metastatic PCa. RESULTS: A total of eight major national and international guidelines/consensus statements published since 2015 and three phase 3 trials were identified. Working group discussions among the multidisciplinary genitourinary oncology panel led to the development of two algorithms: the first addressing management of patients with BCR following radical therapy (post-BCR), and the second addressing management of nmCRPC. The post-BCR algorithm suggests consideration of early salvage treatment in select patients and provides guidance regarding observation vs. intermittent or continuous androgen-deprivation therapy (ADT). The nmCRPC algorithm suggests continued ADT and monitoring for all patients, with consideration of treatment with apalutamide or enzalutamide for patients with high-risk disease (prostate-specific antigen [PSA] doubling time of ≤ 10 months). CONCLUSIONS: Two treatment algorithms have been developed to guide the management of non-metastatic PCa and should be considered in the context of local guidelines and practice patterns.