Can J Urol
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New treatment options for metastatic castration resistant prostate cancer (mCRPC) have become available over the last few years should primary treatments and androgen deprivation therapies fail. While historically not considered to be amenable to immunotherapy, the treatment of advanced prostate cancer using this approach is an area of intense interest and now clinical application. ⋯ A first in class novel treatment modality, sipuleucel-T, is available in the United States for mCRPC. Other immunotherapies are in development and may be available in the near future. Understanding the detailed patient evaluation, initiation and administration of sipuleucel-T as described in this paper, will allow this novel cancer immunotherapy to be better understood and potentially benefit a larger group of appropriately selected patients.
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We summarize the development, definitive trials, and practical use of enzalutamide for practicing urologists and medical oncologists. The care paradigm for patients with metastatic castration resistant prostate cancer (mCRPC) is a changing landscape, with the ongoing discovery of drivers of cancer progression yielding actionable targets for drug development. Since 2010, sipuleucel-T, cabazitaxel, abiraterone with prednisone, radium 223 and enzalutamide have been Food and Drug Administration approved based upon improvement in overall survival in men with mCRPC. ⋯ Enzalutamide is an effective oral therapy for mCRPC, with an overall survival benefit before and following chemotherapy. Toxicity is mild, and seizure risk can be mitigated by careful patient selection. Ongoing studies will help determine the best sequence of novel agents for prostate cancer, along with safe and effective combinations of therapies. Better understanding of tumor characteristics, particularly reliance on the androgen receptor pathway, will lead to personalized approaches to prostate cancer therapy.
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Review
How to approach sequencing therapy in patients with metastatic castration resistant prostate cancer.
Rapid progress has recently been made in understanding the biology of advanced prostate cancer. This has translated into the development of a number of novel agents to treat metastatic castration resistant prostate cancer (mCRPC). ⋯ A number of phase III trials have been published that describe agents which are beneficial in treating mCRPC. Future research will focus on sequencing these agents in a clinically rational and economically viable manner.
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Researchers are constantly seeking ways to improve existing drugs, drug mechanisms of activity, find new indications for old drugs or to develop new drugs to treat urological diseases and conditions. In Canada, tadalafil in a 5 mg daily dosage (old drug), and a new drug, silodosin, have recently become available to treat patients who have benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). ⋯ New therapies--denosumab (to prevent skeletal events) and abiraterone acetate and enzalutamide--were recently approved to treat certain patients with advanced prostate cancer. With the advent of new therapies to treat urological diseases, in many cases, primary management of the patient is often shifted from the urologist to the family physician, and sometimes moved from the oncologist to the urologist.
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Prostate cancer is the second most common cause of cancer death in American men. For patients with adverse pathologic features, postoperative radiotherapy to prostate bed after radical prostatectomy has been shown in randomized studies to improve many important clinical endpoints including overall survival. In this review article, we distinguish adjuvant radiation treatment (ART) from salvage radiation treatment (SRT), discuss the evidences for ART and its potential side effects focusing on the debate concerning the optimal timing of post prostatectomy radiation treatment (RT). ⋯ for patients with adverse pathologic factors, adjuvant radiation treatment after prostatectomy reduces the rate of PSA failure with the potential for significantly improving metastases-free and overall survival. Whether an equivalent survival benefit can be attained with early salvage radiation treatment after biochemical recurrence, is still an area of debate.