<p><strong>Clinicians should offer ADT with either LHRH agonists or antagonists or surgical castration in patients with mHSPC. (<em>Strong Recommendation; Evidence Level: Grade B</em>) </strong></p>
Discussion
Discussion
<p>The use of primary ADT for the management of mHSPC has been the SOC since its discovery by Huggins et al. in the 1940s.<sup>42</sup> Castrate levels of testosterone (<50ng/dL) may be achieved with LHRH analogues, gonadotropin-releasing hormone (GnRH) antagonists, or orchiectomy. These treatments are considered equivalent in cancer control, although they have never been compared in large RCTs. GnRH antagonists and orchiectomy as monotherapy have a rapid onset of action and avoid the ‘testosterone flare’ seen with LHRH analogues alone making them useful in situations needing rapid hormone ablation such as impending spinal cord compression.</p>
<p>At the time of initial publication of this guideline, the methods for achieving castrate levels of testosterone were either surgical or injectable. On December 18, 2020, the FDA approved relugolix as the first oral GnRH receptor antagonist for adult patients with advanced prostate cancer.<sup>86</sup> Approval was based on the phase III HERO study that showed favorable testosterone suppression and adverse effects of oral relugolix (120mg/day) compared to leuprolide.<sup>87</sup> </p>