Updates to the recommendations, tables, treatment algorithms, and/or guideline text in this publication are made with the approval of the SITC Prostate Cancer Immunotherapy Guideline Expert Panel. More information on the SITC Guidelines can be found at sitcancer.org/guidelines.

Update August 2022

Based on the tissue agnostic approvals for pembrolizumab for the treatment of TMB-H and MSI-H/dMMR solid tumors and dostarlimab for the treatment of dMMR solid tumors, and their approved companion diagnostics, the Prostate Cancer CPG has been updated in the following location: - Introduction

References: Pembrolizumab (KEYTRUDA) TMB-H tissue-agnostic approval

Pembrolizumab (KEYTRUDA) MSI-H/dMMR tissue-agnostic approval

Dostarlimab (JEMPERLI) dMMR tissue-agnostic approval

Update 8-24-22

Based on new approvals of immunotherapy agents for the treatment of prostate cancer and new data that has been published since its original publication, the Prostate CPG was updated in the following locations: - Figure 1 - Prostate Cancer Treatment Algorithm

Update 4-7-21

Figure 1 description has been updated, as noted below:

• Prostate carcinoma treatment algorithm: Reading from left to right, patient populations are identified. Options for treatment strategies for specific patient populations are provided in the right-most column in the corresponding row(s). All options provided are of equal preference, and selection of a treatment strategy should take into account patient- and provider-specific considerations as well as the best clinical judgement of the treating physician.

The Prostate Cancer Treatment Algorithm presented in Figure 1 has been updated in multiple areas, as noted below:

Newly Diagnosed -> Metastatic * ADT + Docetaxel * ADT + Enzalutamide * ADT + Abiraterone * ADT + Apalutamide

Recurrent ADT naïve -> Non-metastatic * ADT * Clinical trials

Recurrent ADT naïve -> Metastatic * ADT * ADT + Docetaxel * ADT + Enzalutamide * ADT + Abiraterone

CRPC -> Non-metastatic * ADT + Darolutamide * ADT + Apalutamide * ADT + Enzalutamide

mCRPC* > Minimal/no symptoms * Sipuleucel-T

mCRPC* -> Symptomatic bone-metastases * Radium-23

mCRPC* -> Symptomatic or asymptomatic * Enzalutamide * Abiraterone * Docetaxel * Clinical trial

mCRPC* -> Post-abiraterone or post-enzalutamide * Olaparib(%)

mCRPC* -> Post-docetaxel * Cabazitaxel * Rucaparib(#)

Updated treatment table

Figure 1 footnotes have been updated, as noted below:

• Although not available at the time of publication, for patients with TMB-H or MSI-H/dMMR tumors, pembrolizumab or dostarlimab may be considered, based on FDA-approved indications. (1) Metastasis defined by positive technetium bone scan or CT scan

(*) Treatment with continuous testosterone suppression, and with or without denosumab or zoledronic acid

(#) Patients with deleterious germline or somatic BRCA mutation who have been treated with taxane-based chemotherapy

(%) Patients with deleterious or suspected deleterious germline or somatic homologous recombination repair gene mutation who have progressed after treatment with enzalutamide or abiraterone

Update August 2022

Text has been added to the introduction to include updated information on pembrolizumab and dostarlimab tissue-agnostic approvals, as noted below:

• Since the guideline’s original publication, pembrolizumab was subsequently approved by FDA for the treatment of tumors with high tumor mutation burden (TMB-H) as well as mismatch repair deficient (dMMR)/microsatellite instability high (MSI-H) cancers, which includes a small number of advanced prostate tumors. Dostarlimab (anti-PD-1) has also been approved by the FDA for the treatment of dMMR tumors.

The study that is hyperlinked in this article takes you to a blog post on the Harvard Medical School Prostate Knowlegde blog. They didn't do the study, but they wrote a post about two studies that were conducted on the topic and gave references, which made it nice to follow. After reading the two studies, i found that this title tends to be misleading in its statement. Both studies conducted found that men who ejaculate more than either 7 times per week or more than 21 times a month have a decreased risk of prostate cancer. To me, this is not regular orgasms, that amount seems to be on the higher end for most people and hard to continue through out your life. In conclusion, yes, more ejaculations can reduce your risk of prostate cancer, but the amount needed is high and must be started at a young age to fully reap the benefits.

APA References:

Giles, G.G., Severi, G., English, D.R., McCredie, M.R.E., Borland, R., Boyle, P., & Hopper, J.L. (2003). Sexual factors and prostate cancer. BJU International, 92(3), 211-216.

Leitzmann, M.F., Platz, E.A., Stampfer, M.J., Willett, W.C., Giovannucci, E. (2004). Ejaculation frequency and subsequent risk of prostate cancer. JAMA: Journal of the American Medical Association, 291(13), 1578-1586.

Links: http://jamanetwork.com/journals/jama/fullarticle/198487?=quot;,gt;

http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410X.2003.04319.x/full