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CME: Guidelines for Metastatic Castration-Resistant Prostate Cancer

CME: Guidelines for Metastatic Castration-Resistant Prostate Cancer
Author Information (click to view)

Ethan Basch, MD, MSc

Director, Cancer Outcomes Research Program
Associate Professor, Medicine and Public Health
Lineberger Comprehensive Cancer Center
University of North Carolina, Chapel Hill
Medical Oncologist & Faculty Member
Memorial Sloan Kettering Cancer Center

Ethan Basch, MD, MSc, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

  1. Describe key recommendations made in the American Society of Clinical Oncology and Cancer Care Ontario joint clinical practice guideline on the treatment of men with metastatic castration-resistant prostate cancer.
  2. Explain the importance of including quality-of-life and costs considerations when treating men with metastatic castration-resistant prostate cancer.
  3. Review what needs exist for future research focused on the treatment of men with metastatic castration-resistant prostate cancer as determined by the American Society of Clinical Oncology and Cancer Care Ontario.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwjuly1.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

Christopher Cole, Senior Editor
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Ethan Basch, MD, MSc
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
 AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Ethan Basch, MD, MSc (click to view)

Ethan Basch, MD, MSc

Director, Cancer Outcomes Research Program
Associate Professor, Medicine and Public Health
Lineberger Comprehensive Cancer Center
University of North Carolina, Chapel Hill
Medical Oncologist & Faculty Member
Memorial Sloan Kettering Cancer Center

Ethan Basch, MD, MSc, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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According to current estimates, prostate cancer is the second leading cause of cancer deaths among North American men, with more than 33,000 dying from the disease in 2013. For men with androgen-sensitive metastatic disease, continuous androgen-deprivation therapy is considered the current standard of care, but many of these individuals will go on to develop castration-resistant prostate cancer (CRPC). When this occurs, patients will need additional lines of treatments to support their androgen-deprivation therapy. These additional therapies have the potential to improve survival and quality of life (QOL).

A Welcome Guideline

Recently, the American Society of Clinical Oncology (ASCO) and Cancer Care Ontario (CCO) released a joint clinical practice guideline for treating men with metastatic CRPC. Published in the Journal of Clinical Oncology, the guideline builds upon previous ASCO/CCO recommendations based on a systematic review of 28 randomized clinical trials published between 1979 and 2004. Since the previous guideline was released, an additional 28 trials on systemic therapies have been identified for treating metastatic CRPC, including analyses involving targeted therapies and immunotherapies. These additional randomized trials helped inform the current recommendations.

The updated guideline includes recommendations on systemic therapies indicated for use along with androgen deprivation. They address survival and QOL benefits, side effects, and cost considerations for each of these therapies (Table). The expert panel also recommends that palliative care be offered to all patients, particularly for those exhibiting symptoms or QOL decrements.

Guidelines-MCR-Prostate-Cancer-Callout

Recently, there has been significant progress in the care of advanced prostate cancer, with several new treatments gaining FDA approval over the last few years, says Ethan Basch, MD, MSc, who co-chaired the ASCO/CCO expert writing group that developed the guideline. “When selecting treatments for patients,” he says, “there are many nuances to consider, including the stage of disease and therapies that patients have previously received. The guideline is intended to help clinicians and patients make informed treatment decisions.”

Focus on QOL & Costs

The ASCO/CCO guideline paid particular attention to QOL considerations when developing the recommendations. Dr. Basch says that including QOL data in the guideline can help inform discussions with patients about the extent of potential benefits and harms. ASCO and CCO consider it essential to assure that the goals of care are understood by patients. The guideline notes that many patients with metastatic CRCP misunderstand the goals of care to be curative rather than palliative. This may lead patients to be more accepting of greater toxicity or higher costs based on incorrect assumptions about potential benefits of treatment.

The guideline notes that some metastatic CRCP treatments are associated with considerable cost, leading some patients to potentially decide against specific therapies because of finances. “We need to be especially conscious of cost when treating patients with metastatic CRCP because it can affect access to treatment and QOL,” explains Dr. Basch. “This potential barrier or hardship should be openly discussed with patients.”

The ASCO/CCO guideline notes that many patients have limited access to medical care. Awareness of disparities in access to care should be considered in the context of the guideline. Healthcare providers are recommended to make extra efforts to deliver the highest level of cancer care possible to vulnerable populations. They are also encouraged to enroll a wide range of patient populations into clinical trials to better represent diversity within the community. In addition, the guideline recommends that clinicians be conscious of the role of multiple chronic conditions among patients with metastatic CRCP. A review of all other chronic conditions should be conducted and taken into account when formulating treatment and follow-up plans.

Future Research

Dr. Basch says that more research is needed to determine the optimal sequencing of available therapies for managing metastatic CRCP. “Ongoing clinical trials are exploring this issue as well as the potential benefits and harms of combining various treatments,” he says. “We also need data on the efficacy of drugs in treatment sequences other than those tested in clinical trials.”

Few cost-benefit analyses have been conducted on the management of patients with metastatic CRCP. There is also limited evidence available on the effectiveness of therapies being used in real-world populations and the clinical benefits of lower-cost treatments in low resource contexts. Comparative data are needed regarding QOL and the symptomatic benefits of currently available therapeutic options. The ASCO/CCO panel recommends that efforts be made to develop more rigorously designed symptom and QOL outcome measures in all late-phase clinical trials in metastatic CRPC. “Clinical trials are vital to informing medical decisions and improving cancer care,” Dr. Basch says. “As we learn more about advances in care for metastatic CRPC in the coming years, we will revisit these recommendations and amend them accordingly.”

Readings & Resources (click to view)

Basch E, Loblaw DA, Oliver TK, et al. Systemic therapy in men with metastatic castration-resistant prostate cancer: American Society of Clinical Oncology and Cancer Care Ontario clinical practice guideline. J Clin Oncol. 2014 Sep 8 [Epub ahead of print]. Available at: http://jco.ascopubs.org/content/early/2014/09/03/JCO.2013.54.8404.full.pdf+html.

Basch EM, Somerfield MR, Beer TM, et al. American Society of Clinical Oncology endorsement of the Cancer Care Ontario Practice guideline on nonhormonal therapy for men with metastatic hormone-refractory (castration-resistant) prostate cancer. J Clin Oncol. 2007;25:5313-5318.

Loblaw DA, Virgo KS, Nam R, et al. Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2007 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol. 2007;25:1596-1605.

Loblaw DA, Walker-Dilks C, Winquist E, et al. Systemic therapy in men with metastatic castration-resistant prostate cancer: a systematic review. Clin Oncol (R Coll Radiol). 2013;25:406-430.

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