Factors in Selecting Frontline Therapy for Patients With mCSPC


Focused discussion on drug and patient factors that aid in the selection of frontline therapy for metastatic castration-sensitive prostate cancer.


Neeraj Agarwal, MD: Now coming to Dr Lowentritt—Ben you had great presentations at ASCO [the American Society of Clinical Oncology Annual Meeting] last year on the real-world PSA [prostate-specific antigen] data. We will come to that later, but I would like to ask you: You are a high-volume, busy urologist; you see patients with metastatic castration-sensitive prostate cancer like many other urologists do. What is going on in your mind when you are talking to your patients about abiraterone plus prednisone vs enzalutamide vs apalutamide? What is your experience as far as your patients’ choices are concerned?

Benjamin Lowentritt, MD: I appreciate it, and it is a critical question. I think when we look back, and you framed this in 2019; at the end of 2019 is when apalutamide, enzalutamide got their approvals in the mCSPC [metastatic castration-sensitive prostate cancer] space. Up until then it was just chemotherapy and abiraterone. I believe only 30% of patients saw abiraterone, so you still had the vast majority of people getting ADT [androgen deprivation therapy] alone. I think when I see my patients and I talk to my partners and colleagues today, it’s getting that first level of understanding that we need to intensify their therapy. There’s plenty of evidence that says the standard has long evolved past ADT alone and I think that’s 1 bar to get past on a career of history, on everyone’s history of doing ADT, waiting until that fails and then go on to the next thing. When I’m talking to my patients now, there’s a menu of offerings, and I still do counsel them and encourage them. They learn more about docetaxel as well and refer to my colleagues in medical oncology. It is very clear that an oral option is often favored although I think we are going to see and maybe talk later about ways that that’s going to evolve where they’re not necessarily mutually exclusive. As far as which, abiraterone is still a wonderful medication. The exposure is a little bit longer in this part of the disease state where patients are going to be on this for a longer period of time; there's a slight concern about chronic steroid use in these patients. I don't know if that really weighs heavier than the other concerns about chronic exposure to these medications on other systems in the body but that’s a component of it. I think Dr Liaw rightly pointed out that there’s also usually a cost savings considerably for patients who are going to be on drugs for a long time, so I definitely consider abiraterone as an excellent option. I have used both other options that are approved, apalutamide and enzalutamide, in this space and there are differences. I tend to try to avoid enzalutamide in my more elderly patients. My personal experience is there can be some increased level of problems with equilibrium, memory, or just word finding from those patients over the long haul. I do think we have to recognize that this is going to be a longer course of therapy. Thankfully, they’re all very successful in extending life and having a long course so I have these discussions. I try to do personal assessments. There are some drug-drug interactions, although fairly minimal. Thyroid disease is more of a unique marker for apalutamide, but generally very small incidents and easily managed. I have these discussions, but it ends up being a personal kind of end choice based on a lot of the individual patient factors.

Neeraj Agarwal, MD: Thank you. That was a great summary of your decision-making in your clinic.

Transcript edited for clarity.

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