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Raoul D. Concepcion, MD, Bryan A. Mehlhaff, MD, and Daniel R. Saltzstein, MD, discuss the use of enzalutamide (Xtandi) in post-docetaxel prostate cancer.
Mehlhaff begins the conversation about enzalutamide by noting that prostate cancer remains an androgen sensitive disease. Enzalutamide is similar to Casodex in that it works with the androgen receptor but it does not have agonist qualities. In the clinical trial analyzing enzalutamide, post-chemotherapy patients were randomized to receive the drug or not and saw a 4.8-month overall survival benefit. In addition to the overall survival benefit, progression-free survival improved and PSA values were impressive (25% of patients had a 90% or greater drop in their PSA level), Mehlhaff says. In castration-resistant patients, PSA levels are not as important but patients like to see them drop.
One serious issue with enzalutamide is the risk of seizures. The fact that the seizures occurred (0.9%) in the treatment arm and not the placebo arm is important. Mehlhaff advises that urologists think twice before starting a patient with a history of seizures on enzalutamide.
Saltzstein says that urologists are fortunate to have options for treatment now. Any decision about treatment is shaped by a patient’s health and urologist’s concerns regarding side effects.