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Sequencing Challenges Persist in Metastatic Prostate Cancer

Caroline Seymour
Published: Thursday, Jul 05, 2018

Scott Samuelson, MD

Scott Samuelson, MD

Frontline treatment of patients with metastatic prostate cancer typically includes a taxane-based chemotherapy with docetaxel or an androgen receptor–blocking agent, such as abiraterone acetate (Zytiga). But beyond that, Scott Samuelson, MD, explained that there is no definitive evidence to support the use of one agent over another in subsequent lines of therapy.

State of the Science Summit™ on Prostate Cancer, Samuelson discussed frontline treatment of patients with prostate cancer and subsequent sequencing. 

OncLive: What are the biggest challenges in treating patients with metastatic prostate cancer?

Samuelson: I have been taking care of patients with prostate cancer for the last 9 years. The management is very different now than it was before because we have so many other options. Figuring out the right way to sequence them is an issue. The costs of the medications, especially the oral medications, is another significant challenge for a significant portion of my patients. 

What are some challenges that we have with sequencing?

There are a lot of opinions on what should be done without any real data to necessarily tell us that one agent is better than another. We certainly know what to do in the first-line metastatic setting for most patients.

It is not so clear what to do when patients progress on that because we have a number of options. It is a challenge. It is also an opportunity to talk with our patients about the different side effects and costs. Most patients with prostate cancer end up getting most of the available drugs, but we do not know what the proper sequence is at this point. 

What is your preferred frontline therapy, and what factors do you take under consideration when making this decision?

A lot of the decision depends on a patient’s performance status and whether or not they are a candidate for chemotherapy. Considering a patient’s eligibility for chemotherapy is very important, as it is a very effective therapeutic agent. However, abiraterone acetate and enzalutamide (Xtandi) are also great options.

For a lot of patients, the decision comes down to cost. I take care of a number of patients who live several hours from our clinic. For them, an oral agent tends to be preferable. The costs of some of the oral agents, though usually not prohibitive, do pose an additional challenge for some patients. Those are the patients who would prefer an intravenous agent, which tends to be covered better by insurance.  

Are there any comorbidities that may affect treatment?

Absolutely. Abiraterone is a very well-tolerated drug, but it has significant issues with high blood pressure. That is a common problem I have seen. Enzalutamide is also a wonderful drug, but, compared with abiraterone, it tends to have more fatigue issues. A lot of patients complain about that.

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