Treatment Options for Metastatic Hormone-Sensitive Prostate Cancer, Advances and Barriers – Cora Sternberg
January 23, 2023
Cora Sternberg MD, FACP Professor of Medicine and Clinical Director of the Israel Englander Institute for Precision Medicine, Weill Cornell Medicine, New York.
Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, Massachusetts
The Intensified Treatment Landscape of Metastatic Hormone Sensitive Prostate Cancer (mHSPC) - Russell Szmulewitz
Practice-Changing Data from ARASENS - Statistically Significant Overall Survival - Fred Saad, Bertrand Tombal, and Neal Shore
Can Biology Help Inform Treatment Decisions In the Management of mHSPC? APCCC 2022 Presentation - Gert Attard
Alicia Morgans: Hi, I'm so excited to be here at the PCF annual retreat where I have the opportunity to speak with Dr. Cora Sternberg. And we're really going to dig into the evolution of prostate cancer care over the last 20 years, there's been a lot going on. Certainly, Prostate Cancer Foundation has had a lot of influence in this sphere, but I'd love to hear from your perspective, where have we been, and how did we arrive here?
Cora Sternberg: The Prostate Cancer Foundation has been amazing, and I think I've been at the meeting since they were called CaP CURE many, many years ago. But when you think about prostate cancer, when I think about patients that are more advanced cancer, in the beginning we were only giving androgen deprivation therapy for prostate cancer. And that was the standard of treatment. And unfortunately, it's still what's what many people are still doing in the community. But I think that then we had in 2004 for the first time, something that improved survival, which was docetaxel chemotherapy. And I remember when Tannic was speaking at ASCO, someone said, "I'm proud to be a GU oncologist today." So, we finally had something that improved survival. But since then, we then after the docetaxel, we developed enzalutamide, apalutamide and daraludamide drugs, the novel hormonal therapies, which improved survival after docetaxel.
And then, we started using these drugs in the hormone refractory stage before docetaxel and show that we could improve survival with these drugs. And what's happened more recently is that we've found that the earlier and earlier we move the drugs, if we put them in the metastatic hormone sensitive stage, there's been at least seven large randomized trials showing that giving androgen deprivation therapy with a novel hormonal therapy or docetaxel improves overall survival. And recently, we've had two trials with three different drugs, docetaxel plus androgen deprivation therapy showing you can improve overall survival even further. We heard yesterday from Ken Pienta that the mortality has been the same for many, many years, but I think that's probably true because we have drugs and that improve overall survival. But perhaps not everyone in the community is getting those drugs or in the world is getting those drugs. And these studies show we can improve overall survival and probably you and at the major centers are giving the drugs and that is what's happening.
But it's probably not what's happening everywhere. So, I think that there's a lot of excitement in the prostate cancer community toward treating earlier, treating in the metastatic hormone sensitive state. And also, patients who have M0s castration resistant prostate cancer. We also had three trials showing that putting enzalutamide or abiraterone or apalutamide upfront, we could improve overall survival. Having said that, I think that that's very exciting that we can give all these agents, but to me what's even more exciting is what's going on with genomics and genetics. And that's one of the reasons I moved back to the United States because I wanted to study precision medicine and get more involved with that. Because that wasn't something that we were doing routinely in Italy in a socialized health system where you have to pay for everything for everyone. I don't think it's done, it's done routinely here either.
But listening to the Prostate Cancer Foundation speakers, the basic scientists, everyone is trying to hone down on which patients are retreating. What is the difference between patients who have neuroendocrine prostate cancer, maybe there's many different kinds looking at their DNA, looking at the RNA sequencing to try and see which patients will respond, which patients won't respond. And I think that that's where the change is going to come in the future. We also have a lot of work being done with PSMA, not just scanning, but theranostics and at least two trials that were done in Australian and then an international trial showing that giving Lutetium PSMA can improve overall survival. And we have quite a lot of experience with Lutetium PSMA in our hospital and we're also using Actinium PSMA.
But I think that there's many other kinds of ligands that are being used against HER2 other ones, DL3. And I think that these attached to theranostics and to therapeutics can really change the way we treat our patients in the future and maybe even cure our patients. So, I think that there's a lot going on right now. There's other things going on with artificial intelligence. I think that for pathologists that a way to understand more the single cell, the RNA and the single cell rather than just visually looking at the cells. I think there's a lot going on.
Alicia Morgans: Well, there absolutely is a lot going on, certainly out in practices. I so appreciate that you raised the issue of our advances, but also the issue of the inequitable distribution of these advances. And there's definitely a lot of work even going on and to understand where these differences lie and what the underlying causes may be so that we can try to address some of these as well. And I wonder, as you think about the future, and you've talked about so many things, what are you most excited about?
Cora Sternberg: Well, the PCF has had done a great job. I think this year they also had a whole center, whole section on the disparities in healthcare and showing that some of it certainly has to do with social things, upbringing, access to care for sure, especially in countries as certain African countries, for instance. But I think that that's not the only thing. There's also could be difference in genomics. And I personally have two different grants to study African American men to study their genomics.
And I think that they are have been routinely left out of the genomic studies of the TCGA studies, and we don't know if their genomics could be different too. They have prostate cancer twice as frequently as Caucasians and they die twice as often and present with more aggressive tumors. So, studying their genomics is very important. In some ways it may be that they have more propensity to respond to therapies and more SPOP, for example, which is something that's a good thing to have. But unless we study more and understand more about their genomics, we won't know that.
We need to understand, and dissect that out. How much is genomics, how much is environment, how much is education? How much is access to care? I think all of these things are very important. I think the PCF has done a wonderful job in trying to bring people even from African countries here this time. It's been really up. Absolutely amazing. It's a great meeting.
Alicia Morgans: It absolutely has been. And I so appreciate you talking us through the progress and really helping to set the stage as the Prostate Cancer Foundation and all of us work together to make a difference in this field. Thank you so much for your time and your expertise.
Cora Sternberg: Thank you. I think everyone made a big effort to say how important it was that we all worked together, and that's it. That's been the main theme of this meeting as well.
Alicia Morgans: Absolutely.
Cora Sternberg: Thank you.