Robert Dreicer, MD, MS
Increasing efficacy with immunotherapies in some cancers led to the strategy being deemed Breakthrough of the Year by Science
magazine in 2013.1
However, for Robert Dreicer, MD, and colleagues at the Interdisciplinary Prostate Cancer Congress (IPCC) held March 15, 2014, enthusiasm regarding these therapies for patients with castration-resistant prostate cancer (CRPC) comes with some reservations.
While approved immunotherapy sipuleucel-T (Provenge) improved overall survival (OS) for patients with prostate cancer in a phase III trial,2
it is still finding its place in the arsenal of drugs used to treat the disease, and other immunotherapies tested in prostate cancer have been associated with some drawbacks, according to Dreicer.
“It gets to be a challenge to use a therapy that, from a mechanistic perspective, leaves you with less insight, and that has limited some of what we have done,” said Dreicer regarding combining sipuleucel-T with various targeted therapies.
Dreicer, chair of the Department of Solid Tumor Oncology at the Cleveland Clinic’s Taussig Cancer Institute and professor at the Lerner College of Medicine, presented an evolution of evidence for immunotherapies in prostate cancer, beginning with granuloctye macrophage colony-stimulating factor (GM-CSF), which is used in the development of sipuleucel-T and has been extensively studied in the disease.3
In 2010, he said, the groundbreaking IMPACT trial2
showed an increase in the probability of survival with sipuleucel-T, compared with placebo, in patients with metastatic CRPC who were asymptomatic or minimally symptomatic.
Dreicer reviewed data from a retrospective analysis of subsets within the IMPACT trial,4
which showed that patients with PSA levels ≤22.1 ng/mL had a median OS of 41.3 months compared with 28.3 months for placebo. In patients whose PSA was >22.1 to 50.1 ng/mL, OS was 27.1 and 20.1 months, respectively; in men with PSA levels >50.1 to 134.1, OS was 20.4 and 15 months, respectively; and in the subset of patients with PSAs >134 ng/mL, OS was 18.4 and 15.6 months, respectively.
“What this basically tells us is that if you are going to use an immune-based therapy, using it very early in the clinical course—early meaning castrate, metastatic, asymptomatic, without a crescendo of disease that is about to explode—is the ultimate [setting for] a therapy like this,” he said.
While results from the IMPACT trial brought forth hope for these patients with what Dreicer deemed the “unprecedented development and integration of a novel therapy,” the findings did not come without challenges. Despite its demonstrated impact on OS, sipuleucel-T is not a replacement for treatments designed to induce an objective anti-tumor response in real time, and it has not been shown to improve progression-free survival (PFS), according to Dreicer. He added that access and cost continue to pose problems.
Dreicer mentioned that many of his patients with prostate cancer are also reluctant to put forth the time and effort for this treatment, which is infused in three doses at intervals of 2 weeks, each administered after cell collection (leukapheresis or apheresis). “Men make treatment decisions much differently than women,” he said, mentioning that women are more likely to invest additional time in their own healthcare.
Due to all those factors, “It is not surprising that its uptake has been a little bit challenging,” Dreicer said of sipuleucel-T. But he stressed that the drug is part of a therapeutic paradigm in which multiple agents are used. “You layer this therapy on; it’s not an end all and be all,” he said. “Understanding that this therapy, when falling in the right place, may increase utility, is important.”
Fellow IPCC faculty member Daniel P. Petrylak, MD, agreed that sipuleucel-T is an active agent for prostate cancer, especially when used early on. He acknowledged that cost remains a challenge, but sees a future where this might change.
“I think that cost is certainly an issue, but also innovation helps to drop cost over time. When you are looking at the overall costs, you have to think about what’s being returned: People are able to spend more time with their families; people are able to do other things, just surviving, that are hard to put a price tag on,” said Petrylak, professor of Medicine and Medical Oncology and director of Prostate and Genitourinary Medical Oncology at Yale Cancer Center in New Haven, Connecticut. “So I think that, over time, some of these treatments, with competition, with further innovation, may find that production drops in price. But I think one thing that we have to be careful of is not to throw the baby out with the bathwater, and make sure that we continue to innovate.”