ASCO 2019: Novel Agents in Metastatic CSPC

Transcript: Judd Moul, MD: The message that we want to convey to the urologists who are tuning in is that for the high-volume patients, we should definitely have a multidisciplinary team where those patients need to be seen by a medical oncologist and offered chemotherapy.

Alicia Morgans, MD, MPH: I absolutely agree with that. I think Tanya could expand on that, given some data that were just published or discussed at ASCO [American Society of Clinical Oncology Annual Meeting].

Judd Moul, MD: Yes, we want to get Tanya’s input because she did an outstanding job as a discussant at this ASCO meeting. I’m going to turn the floor over to her.

Neeraj Agarwal, MD: I would like to add that she did a great job in the plenary session.

Judd Moul, MD: Yes, in the plenary session too.

Alicia Morgans, MD, MPH: Fantastic.

Judd Moul, MD: Why don’t you enlighten us on what we learned from ASCO 2019?

Tanya Dorff, MD: ASCO 2019 added 2 new agents. The conversation gets more complicated because apalutamide reported out in the hormone-sensitive space from the TITAN study. Then enzalutamide reported out in the ENZAMET trial at the plenary session. Now we know that we can prolong survival tremendously by using our more powerful agents up front. One key take-home message is that there are probably few men who should not be offered something more than castration when we find them to have metastatic disease.

I think these data don’t tell us which drug is best, so there’s going to be very complex decision-making with the patient, perhaps coming down to access, as Neeraj mentioned earlier. A lot of people will still use docetaxel. We know from the STAMPEDE study, because of that complex design, that there was a period of time when patients were being accrued to both the abiraterone arm and the docetaxel arm. It wasn’t a comparison between the 2 arms, but they were contemporary cohorts. We could see that the benefit was very similar. You get just as much benefit, as best we know, from 1 or the other. The nice thing about the docetaxel is that it’s given for 6 cycles, and then you’re done, versus taking medication on an ongoing basis. Docetaxel is also avoids the prescription co-pay issues. In some ways, it will be nice to have options like enzalutamide and apalutamide that don’t require corticosteroids. I do want to point out that when you use abiraterone in the up-front setting, you use only 5 mg once a day of prednisone. To be honest, I don’t find a lot of corticosteroid toxicity with that dosing.

Judd Moul, MD: OK. That’s good to know.

Tanya Dorff, MD: It becomes more of a replacement and not excess. Still, there are patients for whom that’s going to be attractive.

Judd Moul, MD: Neeraj, do you want to add a comment? What’s been your take on newly diagnosed metastatic disease from ASCO 2019 related to these multiple choices we have?

Neeraj Agarwal, MD: First, to add to what Alicia and Tanya said, we had docetaxel chemotherapy. We had abiraterone, which requires concomitant steroids for many years. Many of our patients do not have either. Some patients do not want chemotherapy or are too frail to have chemotherapy and are not candidates for treatment with long-term steroids, which is required for them because they are going to be treated with abiraterone. There’s also a proportion of patients who really do not like to be treated with any of that—older patients with multiple comorbidities—and they really want to see how Lupron plays out as far as disease control is concerned. They want to try something later, despite an hour of counseling. I think we all have those patients.

The challenges are that you have either chemotherapy, which is not right for many of my older or frailer patients, regardless of volume status, or abiraterone, which requires years of concomitant prednisone use. There’s also the cost. Ever since abiraterone lost its patent, the co-pay has gone up in absence of any co-pay assistance programs. All these factors led to some patients getting continuous androgen deprivation therapy.

This was very challenging for us because we have some patients who are not getting any intensified therapy for multiple reasons. Chemotherapy has its own challenges, and abiraterone has its own challenges. This is where we were 7 days before ASCO. What we’ve seen in the last 5 days has been fascinating. As you said, it’s been 30 years, and we are seeing how rapidly the whole field is unfolding.

We saw TITAN results with the addition of an oral pill. We just talked about apalutamide in the context of M0 [nonmetastatic] CRPC [castration-resistant prostate cancer]. It remains a well-tolerated drug. It doesn’t require concomitant steroids. It’s not associated with all the adverse effects of chemotherapy. I don’t really have to worry about performance status in as many of my patients. Apalutamide, when combined with standard androgen deprivation therapy, significantly improves both radiographic progression-free survival and overall survival.

Transcript Edited for Clarity