Treatment plan — Prostate adenocarcinoma

OpenOnco · Prostate · mCRPC · BRCA-mut · Olaparib (PROfound)

← Back to gallery Feedback on this case

Synthetic educational example. Do not self-treat: a qualified treating physician must verify the sources, patient data, contraindications, and final plan.

OpenOnco · Treatment Plan

Treatment plan — Prostate adenocarcinoma

PLAN-PROSTATE-MCRPC-BRCA-001-V1 · v1 · 2026-08-18

Patient

PROSTATE-MCRPC-BRCA-001 · Algorithm: ALGO-PROSTATE-MCRPC-1L

DiagnosisProstate adenocarcinoma

MOH / ICD-10C61

ICD-O-38140/3; C61.9

StageIV

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

✅ Covered biomarkers (matched in KB)

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
ESCAT: clinical review pendingBIO-HRR-PANEL	ATM germline pathogenic	IB	Molecular evidence option SRC-CIVIC: Level A (Supports, Poor Outcome) SRC-CIVIC: Level B (Supports, Poor Outcome) Resistance or avoidance signal SRC-CIVIC: Level D ⚠ Resistance Trial or research option SRC-CIVIC: Level C (Supports, Sensitivity/Response) SRC-CIVIC: Level D (Supports, Sensitivity/Response)	ATM germline pathogenic in mCRPC: olaparib approved per PROfound (Cohort A included ATM); benefit smaller than BRCA but FDA/EMA-labeled. Talazoparib+enzalutamide and olaparib+abiraterone also include ATM in HRR- mutated populations. ESCAT IB / OncoKB Level 1.	olaparib monotherapy (post-NHA) talazoparib + enzalutamide (1L, HRR-mut)	SRC-NCCN-PROSTATE-2025 SRC-ESMO-PROSTATE-2024 SRC-EAU-PROSTATE-2024
ESCAT: clinical review pendingBIO-HRR-PANEL	ATM somatic loss-of-function	IB	Molecular evidence option SRC-CIVIC: Level A (Supports, Poor Outcome) SRC-CIVIC: Level B (Supports, Poor Outcome) Resistance or avoidance signal SRC-CIVIC: Level D ⚠ Resistance Trial or research option SRC-CIVIC: Level C (Supports, Sensitivity/Response) SRC-CIVIC: Level D (Supports, Sensitivity/Response)	Somatic ATM loss-of-function in mCRPC: PROfound enrolled both germline and somatic ATM in Cohort A; olaparib indication covers both. ESCAT IB / OncoKB Level 1.	olaparib monotherapy (post-NHA, FDA) talazoparib + enzalutamide (1L, HRR-mut)	SRC-NCCN-PROSTATE-2025 SRC-ESMO-PROSTATE-2024 SRC-EAU-PROSTATE-2024
ESCAT: clinical review pendingBIO-BRCA1-BRCA2-GERMLINE	BRCA1 germline pathogenic	IA	Molecular evidence option SRC-CIVIC: Level A (Supports, Sensitivity/Response) SRC-CIVIC: Level B (Supports, Better Outcome) Resistance or avoidance signal SRC-CIVIC: Level B ⚠ Resistance	BRCA1 germline pathogenic in mCRPC: olaparib improves rPFS and OS post-NHA (PROfound Cohort A, de Bono 2020); rucaparib (TRITON2/3) and niraparib (MAGNITUDE BRCA subset) also approved. 1L olaparib + abiraterone (PROpel) and niraparib + abiraterone (MAGNITUDE) extend rPFS in HRR-positive mCRPC. ESCAT IA / OncoKB Level 1.	olaparib monotherapy (post-NHA) olaparib + abiraterone + prednisone (1L) niraparib + abiraterone + prednisone (1L) talazoparib + enzalutamide (1L) rucaparib monotherapy (post-NHA + taxane)	SRC-NCCN-PROSTATE-2025 SRC-ESMO-PROSTATE-2024 SRC-EAU-PROSTATE-2024
ESCAT: clinical review pendingBIO-HRR-PANEL	BRCA1 somatic loss-of-function	IA	Molecular evidence option SRC-CIVIC: Level A (Supports, Sensitivity/Response) SRC-CIVIC: Level B (Supports, Better Outcome) Resistance or avoidance signal SRC-CIVIC: Level B ⚠ Resistance	Somatic BRCA1 loss-of-function in mCRPC: PROfound enrolled both germline and somatic; olaparib benefit equivalent. PARPi labels in prostate cover both gBRCA and sBRCA. ESCAT IA / OncoKB Level 1.	olaparib monotherapy (post-NHA) olaparib + abiraterone (1L) niraparib + abiraterone (1L) talazoparib + enzalutamide (1L)	SRC-NCCN-PROSTATE-2025 SRC-ESMO-PROSTATE-2024 SRC-EAU-PROSTATE-2024
ESCAT: clinical review pendingBIO-BRCA1-BRCA2-GERMLINE	BRCA2 germline pathogenic	IA	Molecular evidence option SRC-CIVIC: Level A (Supports, Sensitivity/Response) SRC-CIVIC: Level B (Supports, Better Outcome) Resistance or avoidance signal SRC-CIVIC: Level B ⚠ Resistance Trial or research option SRC-CIVIC: Level C (Supports, Sensitivity/Response)	BRCA2 germline pathogenic in mCRPC: largest PARPi benefit in HRR pathway (PROfound Cohort A); olaparib post-NHA, 1L olaparib+abiraterone (PROpel), niraparib+abiraterone (MAGNITUDE), talazoparib+enzalutamide (TALAPRO-2) all approved. ESCAT IA / OncoKB Level 1.	olaparib monotherapy (post-NHA) olaparib + abiraterone (1L) niraparib + abiraterone (1L) talazoparib + enzalutamide (1L) rucaparib monotherapy	SRC-NCCN-PROSTATE-2025 SRC-ESMO-PROSTATE-2024 SRC-EAU-PROSTATE-2024
ESCAT: clinical review pendingBIO-HRR-PANEL	BRCA2 somatic loss-of-function	IA	Molecular evidence option SRC-CIVIC: Level A (Supports, Sensitivity/Response) SRC-CIVIC: Level B (Supports, Better Outcome) Resistance or avoidance signal SRC-CIVIC: Level B ⚠ Resistance Trial or research option SRC-CIVIC: Level C (Supports, Sensitivity/Response)	Somatic BRCA2 loss-of-function in mCRPC: PROfound included sBRCA; olaparib benefit equivalent to germline. Labels cover germline OR somatic. ESCAT IA / OncoKB Level 1.	olaparib monotherapy olaparib + abiraterone (1L) niraparib + abiraterone (1L) talazoparib + enzalutamide (1L)	SRC-NCCN-PROSTATE-2025 SRC-ESMO-PROSTATE-2024 SRC-EAU-PROSTATE-2024
ESCAT: clinical review pendingBIO-HRR-PANEL	CHEK1 somatic loss-of-function	IIIA	Molecular evidence option SRC-CIVIC: Level A (Supports, Sensitivity/Response)	Somatic CHEK1 loss-of-function in mCRPC: rare; PROfound included CHEK1 in Cohort B but small sample. Olaparib FDA label includes CHEK1 in HRR list. ESCAT IIIA / OncoKB Level 3B.	olaparib monotherapy (post-NHA, FDA HRR label)	SRC-NCCN-PROSTATE-2025 SRC-EAU-PROSTATE-2024
ESCAT: clinical review pendingBIO-HRR-PANEL	CHEK2 germline pathogenic	IB	Molecular evidence option SRC-CIVIC: Level A (Supports, Sensitivity/Response) SRC-CIVIC: Level B (Supports, Predisposition) Resistance or avoidance signal SRC-CIVIC: Level B ⚠ Resistance	CHEK2 germline pathogenic in mCRPC: included in PROfound Cohort B; olaparib FDA HRR label (post-NHA) includes CHEK2 (FDA), though EMA label restricts to BRCA1/2. ESCAT IB (FDA jurisdiction) / OncoKB Level 1.	olaparib monotherapy (post-NHA, FDA HRR label) talazoparib + enzalutamide (HRR-mutated 1L)	SRC-NCCN-PROSTATE-2025 SRC-ESMO-PROSTATE-2024 SRC-EAU-PROSTATE-2024
ESCAT: clinical review pendingBIO-HRR-PANEL	CHEK2 somatic loss-of-function	IB	Molecular evidence option SRC-CIVIC: Level A (Supports, Sensitivity/Response) SRC-CIVIC: Level B (Supports, Predisposition) Resistance or avoidance signal SRC-CIVIC: Level B ⚠ Resistance	Somatic CHEK2 in mCRPC: PROfound enrolled both g/s; FDA olaparib HRR label includes CHEK2. ESCAT IB / OncoKB Level 1.	olaparib monotherapy (FDA HRR label) talazoparib + enzalutamide (HRR-mutated 1L)	SRC-NCCN-PROSTATE-2025 SRC-ESMO-PROSTATE-2024 SRC-EAU-PROSTATE-2024

⚠️ Not included in plan

Biomarker	Status
BIO-GLEASON-ISUP	BIO definition in KB; no ESCAT BMA entry — verify with clinician
BIO-PSA	BIO definition in KB; no ESCAT BMA entry — verify with clinician
BIO-BRCA-GERMLINE	BIO definition in KB; no ESCAT BMA entry — verify with clinician

Primary current-line option

Aggressive plan

★ DEFAULT

Indication

IND-PROSTATE-MCRPC-1L-PARPI

Regimen

Olaparib monotherapy (mCRPC, HRR-mutant)

Drugs + NSZU

Olaparib (DRUG-OLAPARIB) 300 mg PO BID continuous · Until progression or unacceptable toxicity · PO ⚠ NSZU — not for this indication

Supportive care

SUP-BONE-HEALTH-PROSTATE

Reason

Primary current-line option selected by ALGO-PROSTATE-MCRPC-1L at step 1; branch-driving red flag: RF-PROSTATE-HIGH-RISK-BIOLOGY.

Other current-line alternatives (1 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Standard plan

Indication

IND-PROSTATE-MCRPC-2L-LU-PSMA

Regimen

Lutetium-177 PSMA-617 radioligand therapy

Drugs + NSZU

Lutetium-177 PSMA-617 (DRUG-LUTETIUM-177-PSMA) 7.4 GBq IV · q6 weeks × 6 cycles · IV ✗ Not registered in UA

Supportive care

SUP-BONE-HEALTH-PROSTATE

Reason

Current-line alternative presented for HCP consideration

Why this branch was chosen

Triggers from the patient profile that fired and drove the chosen branch.

Step 1 → branch IND-PROSTATE-MCRPC-1L-PARPI

RF-PROSTATE-HIGH-RISK-BIOLOGY ★ winner: Germline or somatic BRCA1/2 mutation OR broader HRR pathway alteration (ATM, CDK12, PALB2, etc.) — predicts PARPi response; opens olaparib/talazoparib indication in mCRPC. SRC-NCCN-PROSTATE-2025SRC-ESMO-PROSTATE-2024

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-CBC	Complete Blood Count with Differential	Critical	lab	—	standard
TEST-CMP	Comprehensive Metabolic Panel	Critical	lab	—	standard
TEST-PSA-SERUM	Serum PSA	Critical	—	—	all tracks
TEST-BONE-SCAN	Whole-body Tc-99m MDP bone scintigraphy	Standard	—	—	aggressive
TEST-GERMLINE-BRCA-PANEL	Germline BRCA1/2 + HRR panel sequencing	Standard	—	CSD Lab: M089	aggressive
TEST-PSMA-PET	PSMA-PET/CT (Ga-68 or F-18)	Standard	—	—	standard
TEST-SOMATIC-HRR-PANEL	Tumor-tissue (or ctDNA) HRR-pathway NGS panel	Standard	—	CSD Lab: M065 CSD Lab ✓ (code TBC)	aggressive
TEST-TESTOSTERONE-SERUM	Serum total testosterone	Standard	—	—	aggressive

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Metastatic prostate cancer with malignant epidural spinal cord compression (MESCC): new motor deficit, sensory level, cauda equina syndrome, severe back pain with vertebral metastasis — prostate is the most common solid tumor cause of MESCC
Per NCCN-PROSTATE supportive-care + EAU-PROSTATE 2024: dexamethasone 10 mg IV bolus + 4 mg q6h, MRI whole spine within 24 h, multidisciplinary surgical/RT review. Patchell criteria for surgery (single-level, ≥48 h expected survival…
RF-PROSTATE-CORD-COMPRESSIONSRC-NCCN-PROSTATE-2025SRC-ESMO-PROSTATE-2024SRC-EAU-PROSTATE-2024
Germline or somatic BRCA1/2 mutation OR broader HRR pathway alteration (ATM, CDK12, PALB2, etc.) — predicts PARPi response; opens olaparib/talazoparib indication in mCRPC.
PROfound (olaparib) + TALAPRO-2 (talazoparib + enzalutamide) + MAGNITUDE (niraparib + abiraterone) define PARPi indications. BRCA1/2 largest benefit; broader HRR cohort smaller but positive. Germline + somatic testing recommended for ALL…
RF-PROSTATE-HIGH-RISK-BIOLOGYSRC-NCCN-PROSTATE-2025SRC-ESMO-PROSTATE-2024
Pre-treatment HBV/HCV/HIV serology + dental evaluation (denosumab/zoledronate ONJ risk; lutetium-PSMA xerostomia) standard for mCRPC initiation.
Cross-disease HBV reactivation handled by RF-UNIVERSAL-HBV-REACTIVATION- RISK. Dental clearance pre-bone-modifying-agent unique to bone-meta diseases (prostate, breast, MM).
RF-PROSTATE-INFECTION-SCREENINGSRC-NCCN-PROSTATE-2025SRC-ESMO-PROSTATE-2024
Renal dysfunction (CrCl <50 mL/min) or severe hepatic impairment (Child-Pugh C) — limits PARPi (olaparib renal-cleared) and ARPI (abiraterone hepatic) dosing.
Olaparib requires CrCl ≥31 (with dose-mod) for safe use; <30 avoid. Abiraterone Child-Pugh C: avoid. Surfaces in MDT as need for renal/ hepatic input.
RF-PROSTATE-ORGAN-DYSFUNCTIONSRC-NCCN-PROSTATE-2025SRC-ESMO-PROSTATE-2024
Spinal cord compression OR rapid PSA doubling time (<3 months) OR new visceral metastases — emergency or aggressive-progression flag requiring urgent intervention or treatment intensification.
Spinal cord compression: emergent neurosurgical / RT consult AND immediate testosterone suppression (degarelix preferred for speed vs LHRH agonists). PSA doubling time <3 months in nmCRPC: criterion for ARPI initiation per NCCN. Visceral…
RF-PROSTATE-TRANSFORMATION-PROGRESSIONSRC-NCCN-PROSTATE-2025SRC-ESMO-PROSTATE-2024

CONTRA-AGGRESSIVE

Hard contraindications to escalation

—

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-PROSTATE-MCRPC-2L-LU-PSMA)

НІКОЛИ не призначати без PSMA-ПЕТ/КТ-підтвердження — тільки PSMA-позитивна хвороба
Не призначати при будь-якому PSMA-негативному осередку метастазування
Не ігнорувати ниркову функцію — лютецій виводиться нирками; ГФК <30 = протипоказання
Не пропускати тестування HRR/BRCA до призначення — PARPi перевершує при BRCA1/2
Не призначати без підтримки ядерно-медичного відділу з радіотерапевтичною ліцензією

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Aggressive plan

Induction · Olaparib monotherapy (mCRPC, HRR-mutant)

28-day cycles × Continuous until progression

Standard plan

Induction · Lutetium-177 PSMA-617 radioligand therapy

42-day cycles × 6 (extend to 8 if responding and tolerated, per protocol)

MDT brief

Discussion questions (2, 0 blocking)

OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist
OQ-BIOMARKER-PSMA-PET
What is the status of PSMA-PET imaging avidity (BIO-PSMA-PET)? It is required by track(s): IND-PROSTATE-MCRPC-2L-LU-PSMA. Expected value: PSMA-PET/CT POSITIVE — MANDATORY (68Ga-PSMA-11 or 18F-DCFPyL preferred).
A treatment-track biomarker requirement is missing from the patient profile; the MDT should verify the test result, method, specimen, and date before relying on this option.
→ medical_oncologist

MDT talk tree (4 steps)

#	Owner	Topic	Action
1	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
2	medical_oncologist	Biomarker status	What is the status of PSMA-PET imaging avidity (BIO-PSMA-PET)? It is required by track(s): IND-PROSTATE-MCRPC-2L-LU-PSMA. Expected value: PSMA-PET/CT POSITIVE — MANDATORY (68Ga-PSMA-11 or 18F-DCFPyL preferred).
3	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
4	molecular_geneticist	Specialist review	Indication references an actionable genomic biomarker — mutation / target / actionability interpretation needed.

Skills (recommended) — for consideration (2)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
Molecular geneticist / molecular oncologist recommended
Indication references an actionable genomic biomarker — mutation / target / actionability interpretation needed.

Data quality

Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.

Biomarker coverage: 3/4 known (75%), 1 missing, 0 default-track gaps
Unevaluated RedFlags: RF-ATM-CONFIRMED-CARRIER, RF-ATM-FAMILY-HISTORY-SUSPICION, RF-BRCA-CONFIRMED-CARRIER, RF-BRCA-HBOC-FAMILY-HISTORY-SUSPICION, RF-CASCADE-BRCA-FDR-POSITIVE, RF-CASCADE-FAP-FDR-POSITIVE, RF-CASCADE-LYNCH-FDR-POSITIVE, RF-CHAARTED-HIGH-VOLUME-MHSPC, RF-CHEK2-CONFIRMED-CARRIER, RF-CHEK2-FAMILY-HISTORY-SUSPICION, RF-FAP-FAMILY-HISTORY-SUSPICION, RF-LATITUDE-HIGH-RISK-MHSPC, RF-LYNCH-CONFIRMED-CARRIER, RF-LYNCH-FAMILY-HISTORY-SUSPICION, RF-PAN-ATM-CHEK2-CDK12-PARPI-CANDIDATE, RF-PAN-BRCA-SOMATIC-PARPI-CANDIDATE, RF-PAN-PALB2-PARPI-CANDIDATE, RF-PROSTATE-AR-AMP-ARSI-RESISTANCE, RF-PROSTATE-AR-V7-ARSI-RESISTANCE, RF-PROSTATE-CORD-COMPRESSION, RF-PROSTATE-HIGH-RISK-BIOLOGY, RF-PROSTATE-INFECTION-SCREENING, RF-PROSTATE-ORGAN-DYSFUNCTION, RF-PROSTATE-PSA-PROGRESSION, RF-PROSTATE-TMPRSS2-ERG-PROGNOSTIC, RF-PROSTATE-TRANSFORMATION-PROGRESSION

Missing biomarker	Label	MDT owner	Default track	Required by	Next action
`BIO-PSMA-PET`	PSMA-PET imaging avidity	medical_oncologist	no	IND-PROSTATE-MCRPC-2L-LU-PSMA	Verify result, method, specimen, and report date before sign-off. Expected/constraint: PSMA-PET/CT POSITIVE — MANDATORY (68Ga-PSMA-11 or 18F-DCFPyL preferred)

Technical MDT skill metadata (2/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Sign-offs	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	0	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	0	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	0	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	0	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	0	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	0	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	0	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	0	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	0	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	0	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	0	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	0	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	0	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	0	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	0	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	0	cellular_therapy

Sources cited

SRC-ESMO-PROSTATE-2024: ESMO Clinical Practice Guideline on Prostate Cancer (2024)
SRC-NCCN-PROSTATE-2025: NCCN Clinical Practice Guidelines — Prostate Cancer (2025.v3)
SRC-VISION-PSMA-SARTOR-2021: Lutetium-177-PSMA-617 for Metastatic Castration-Resistant Prostate Cancer (2021)

Experimental options (clinical trials)

Last synced: 2026-08-18 · ctgov.

No active trials matched this scenario in ctgov.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Aggressive plan Olaparib monotherapy (mCRPC, HRR-mutant) (REG-OLAPARIB-MONO)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan Lutetium-177 PSMA-617 radioligand therapy (REG-LUTETIUM-PSMA) 1/1 component drug(s) not registered in Ukraine +1	✗ not registered	✗ out-of-pocket	₴-? — verify pathway	not recorded

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-08-18.

plan_id: PLAN-PROSTATE-MCRPC-BRCA-001-V1 | version: 1 | generated: 2026-08-18T07:59:48.725348+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.