Current Perspective on Management of Advanced Prostate Cancer: ‘Abundance of First-Line Options’
Posted: Thursday, December 3, 2020
During the NCCN 2020 Virtual Annual Conference, Sandy Srinivas, MD, of Stanford Cancer Institute, outlined the current recommendations for the treatment of advanced prostate cancer, based on recent trials' results. Highlights of this presentation were published in JNCCN–Journal of the National Comprehensive Cancer Network.
Dr. Srinivas noted that four large trials support the use of androgen receptor inhibitors in castration-naive prostate cancer: LATITUDE (abiraterone acetate), ARCHES (enzalutamide), TITAN (apalutamide), and ENZAMET (enzalutamide). “LATITUDE was designed as a trial for patients with high-volume disease, 98% of whom met the criteria. ARCHES, TITAN, and ENZAMET had a decreased percentage of patients with high-volume disease, ranging from 52% to 62%. Disease volume has become an important criterion selection of therapy in metastatic castration-naive prostate cancer,” Dr. Srinivas emphasized.
In addition, Dr. Srinivas reviewed various other classes of agents approved for the treatment of metastatic castration-naive prostate cancer. They include hormonal agents (abiraterone acetate, enzalutamide), immunotherapies (sipuleucel-T), pembrolizumab for microsatellite instability–high tumors, cytotoxic agents (docetaxel, cabazitaxel), and agents that cause DNA damage (radium-223). “We have a shuffling of the deck, because many of these drugs are being used in earlier disease states,” she commented.
The choice of second-line therapy depends on which drug the patient was given as first-line therapy. If first-line therapy was abiraterone acetate or enzalutamide, then docetaxel or sipuleucel-T is preferred. If docetaxel was given in the first-line, then abiraterone acetate, enzalutamide, or cabazitaxel can be given. “Sequencing of these drugs is unclear and depends on first-line treatment,” she maintained.
Looking toward the future, Dr. Srinivas noted, promising emerging approaches include PARP inhibitors in selected patients with BRCA2 mutations and lutetium-177, a prostate-specific membrane antigen-directed therapy. Of note, the PROfound trial showed the PARP inhibitor olaparib had the most impact on patients who had metastatic castration-naive prostate cancer and BRCA mutations.
Disclosure: For Dr. Srinivas’ disclosures, visit jnccn.org.
