Every patient presenting with metastatic disease should be referred to a medical oncologist and discussed at an MDM before starting therapy unless it is an emergency.

Androgen deprivation therapy

ADT is the standard treatment for men with advanced prostate cancer. There is little survival benefit related to initiating ADT treatment early (rather than later). Therefore, the timing of ADT treatment initiation is often related to balancing the risk of significant side effects of ADT (many of which increase over time) against the unwanted effects of the disease. When ADT therapy is indicated it can be initiated by any lead clinician after an appropriate multidisciplinary team discussion unless it is an emergency.

Clinicians prescribing ADT (including general practitioners and clinical practice nurses) should be trained in its administration and be knowledgeable about the long-term side effects of ADT. Side effects should be monitored through regular patient reviews.

Other systemic therapy

For patients with metastatic disease, cytotoxic chemotherapy, novel androgen receptor signalling inhibitors, bisphosphonates and RANK ligand inhibitors may be of benefit.

Depending on both patient and disease factors, an upfront combination of systemic agents (e.g. docetaxel chemotherapy or androgen receptor signalling inhibitors and ADT) may result in more significant survival benefits than treatment sequencing.

Consideration should be given to the metabolic, cardiovascular and bone health of the patient and preventative measures instituted as appropriate. There should be a clear understanding with the care team as to who will undertake monitoring (the general practitioner, oncologist, urologist or radiation oncologist).

Timeframes for starting treatment

Treatment should begin within three months of the diagnosis if asymptomatic, or within four weeks if symptomatic or extensive metastatic disease is present on imaging.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

• Fellow of the Royal Australian College of Physicians (or equivalent)
• adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

• anti-cancer treatment administration
• specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
• the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

• adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

• a clearly defined path to emergency care and advice after hours
• access to diagnostic pathology including basic haematology and biochemistry, and imaging
• cytotoxic drugs prepared in a pharmacy with appropriate facilities
• occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
• guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
• coordination for combined therapy with radiation therapy, especially where facilities are not co-located
• appropriate molecular pathology access