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Castration-resistant prostate cancer (CRPC) includes a wide range of disease types: from patients without metastases or symptoms with rising prostate-specific antigen (PSA) levels despite androgen deprivation therapy (ADT) to patients with metastases and significant debilitation due to cancer symptoms. The panel recommends that ADT be continued in the presence of CRPC (Fig. 1). There is no standard of care and no approved regimen in M0 CRPC. Anti-androgen (AA) therapy should be discontinued if patients are receiving these agents. Secondary hormonal treatments (not including abiraterone or enzalutamide) may be attempted (Level 3, Grade C). It is suggested to screen for bone metastases with bone scans and monitor for lymph node and visceral metastases/progres-sion with imaging of the abdomen and chest. Patients with a rapid PSA doubling time (PSADT) (<8 months) are at risk for developing earlier metastases. Imaging in these patients should be performed every 3 to 6 months. Patients with slower PSA DT (>12 months) should be screened every 6 to 12 months (Grade C). Abiraterone acetate 1000 mg/day plus prednisone 5 mg/ twice daily is recommended as first-line therapy (Level 1, Grade A). Abiraterone acetate significantly improved radio-graphic progression-free survival, time to pain progression and time to chemotherapy initiation; it also delayed ECOG (Eastern Cooperative Oncology Group) performance status deterioration. There was a non-significant 5-month improvement in overall survival. Treatment with docetaxel 75 mg/m 2 every 3 weeks plus 5 mg oral prednisone twice daily should be offered (Level 1, Grade A). Docetaxel was shown to improve overall survival, disease control, symptom palliation and quality of life. However, the timing of docetaxel therapy in men with evidence of metastases, but without symptoms, should be discussed with patients; therapy should be individualized based on the patient's clinical status and preference. AA should be discontinued if patients are on it to test for an AA withdrawal response (AAWD). Introduction of, or changes to, a first-generation AA or the use of cortico-steroids with or without ketoconazole may be considered (Level 3 Grade C).

CUA-CUOG Guidelines for the Management of Castration Resistant Prostate Cancer (CRPC): 2013 Update