Dr. Siddiqui on Selecting Between Antiandrogen Agents in Nonmetastatic CRPC

Bilal A. Siddiqui, MD, assistant professor, Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, discusses selecting between available antiandrogen agents in nonmetastatic castration-resistant prostate cancer (CRPC).

Currently, the antiandrogen agents enzalutamide (Xtandi), apalutamide (Erleada), and darolutamide (Nubeqa) are FDA approved for use in men with nonmetastatic CRPC, Siddiqui says. The regulatory decisions were based on findings from 3 randomized trials that each enrolled over 1000 patients with nonmetastatic CRPC who had a prostate-specific antigen doubling time of 10 months or less and no evidence of distant metastatic disease by conventional imaging. The primary end point of the studies was metastasis-free survival (MFS).

The results of the studies demonstrated similar MFS and overall survival improvements across the 3 agents compared with placebo, Siddiqui explains. As such, treatment selection should be informed by the individual safety profiles of enzalutamide, apalutamide, and darolutamide.

Patients with a history of seizures are not suited for darolutamide as it has demonstrated lower blood-brain barrier penetrance compared with enzalutamide and apalutamide. Other considerations to inform selection include the risk of rash, which is greatest with apalutamide, drug-drug interactions, patient comorbidities, and cost, Siddiqui concludes.