Expert perspectives on metastatic hormone-sensitive prostate cancer and the current state of the treatment armamentarium.
Alicia Morgans, MD, MPH: Let’s move on to our next module. We’ll talk about metastatic hormone-sensitive prostate cancer. Scott, let’s start with you. Can you review the landscape of treatment as we know it?
Scott T. Tagawa, MD, MS, FACP: Sure. There are some discussions, and it’s likely the terminology will change. Officially, by working group and ASCO [American Society of Clinical Oncology] definitions, we’re talking about metastatic noncastrate. When they start therapy, their serum level of testosterone is normal, or at least not very low. But castration-sensitive and hormone-sensitive are more or less synonyms, just to put that out there. There are 2 main flavors of patients walking in the door: those with that first diagnosis and those who have recurrence. I’ll mention that first.
For some patients who have an entry primarily, that’s a consideration. I’ll leave it at that, because I’m giving an overview. The nice thing about this disease state is that we have a lot of treatment options. These treatment options don’t improve things by just a little—“a little” is my scientific term—by hazard ratio for weeks or months. These are significant improvements in risk reduction for death that translate into years of survival, even when the same drugs are used later. More specifically, ADT [androgen deprivation therapy] has been in the backbone. As a general rule, that can be a surgical bilateral orchiectomy; otherwise, we use LHRH antagonists or agonists.
Unless there’s an exception, which is rare, they should be getting something else, such as an AR [androgen receptor] pathway inhibitor or chemotherapy. We’ll go over some recent data for the triplets. ADT and docetaxel, at least in some of the subsets that present with metastatic disease and have higher-volume disease, do better when we add in a potent AR pathway inhibitor, as well as data for AR pathway inhibitors having a significant overall survival vs ADT alone. I’ll emphasize that it’s a rare-patient population that should be getting only 1 drug.
Alicia Morgans, MD, MPH: Thank you. That’s going to be a key message as we go through this entire section, that the standard of care is ADT plus a partner, whether that’s an AR-targeted agent, ADT plus docetaxel, or even a triplet as you mentioned. Thank you so much for mentioning that.
Transcript edited for clarity.