Recent Updates in Treatment of Non-Metastatic Castration Resistant Prostate Cancer - Episode 6
Dr Aaron Berger comments on quality of life data and the role of patient preference in nmCRPC.
Audrey Sternberg: Can you discuss quality-of-life data with next-generation androgen receptor inhibitors?
Aaron Berger, MD: With apalutamide [Erleada]…the data along with quality-of-life surveys showed that it wasn’t significantly different for the patients on treatment vs the patients on placebo. This was similar to their other trial for metastatic disease. As far as darolutamide [Nubeqa] goes, the overall incidence of significant adverse events over placebo wasn’t significant in any of the categories either. Those 2 certainly have some pretty good quality-of-life data to indicate that this shouldn’t be a huge effect on the quality of life. And although enzalutamide [Xtandi] didn’t have the quality-of-life surveys along with their study, most of us who have experience with enzalutamide recognize that, in general, it’s also quite well tolerated as far as quality of life for most patients. Because it was the first to market, we’ve had the most experience with it.
Audrey Sternberg: Can you comment on quality-of-life data with these agents in the metastatic castration-resistant prostate cancer setting, specifically from the ODENZA, ARCHES, and TITAN trials?
Aaron Berger, MD: Not surprisingly, because it’s the same medication, the adverse event profile for all these patients in the metastatic space is very similar to the nonmetastatic space. Those patients do have metastasis and their disease is a little more advanced, but as far as comparing it to placebo in those trials, they very closely mirror what we saw in the nonmetastatic trials. There haven’t been any studies that I’ve been super impressed with to say, “We can use this medication in nonmetastatic, but we shouldn’t use it in metastatic because the adverse effects are so much worse.” They’re very similar, as we’d expect, given it’s the same medication and dosing. It’s not like these medications have different dosages for nonmetastatic or metastatic. They’re all basically given the exact same way for the 2 disease states. Not surprisingly, the data show that the percentages for quality of life and significant adverse events over placebo are very similar between the nonmetastatic and metastatic spaces.
Audrey Sternberg: In your view, what’s the role of patient preference in therapy selection? When and how often should one have these discussions with their patients?
Aaron Berger, MD: That’s a good question. At least where I am in my practice, I don’t have a lot of patients who have come in and have done a lot of research, read the studies, and gone online and come in with preconceived notions of what they should be getting. I know colleagues around the country with patients who may be a little more proactive and say, “This is what I read. This is what I should be taking. This is what I want you to prescribe for me.” In my practice, that’s not something we see very frequently, but we certainly want to give them the option. But it’s somewhat challenging when you have 3 really good medications that all work very similarly. Their mechanism of action is basically identical. The studies show they all work very similarly. Statisticians could go through and say, “This one’s slightly better at this, and this is slightly better at that,” but in general, they’re all very effective and showed statistical significance in terms of metastasis-free survival and overall survival.
From an effectiveness standpoint, there aren’t huge differences. When you give patients the option of choosing from Nubeqa, Erleada, and Xtandi, a lot of times they say, “I don’t know, doctor. What do you think we should do?” It’s not something that the patients have a lot of knowledge of, especially in that first visit where they’re seeing me for nonmetastatic castration-resistant disease. I don’t know if any of us can tell them, “This one’s better than the other. You should do this because you have that.” They all work well. They all have pretty good adverse effect profiles.
Sometimes it’s an insurance issue. Sometimes it’s a coverage issue. That certainly will bear itself out when you try to prescribe something. But up front, if there’s some glaring issue where they shouldn’t take one vs the other, then that’s an easier choice. If they have no significant other comorbidities, it’s prescriber preference. And if the patients hear about something or read about one that they want to do instead, I certainly have no issue making a switch or doing something different. But there’s not a huge driving force to do one vs the other, because they’re all very effective and pretty well tolerated.
This transcript has been edited for clarity.