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A meditation on the need and utility for Sip T in 2018. On a nearly weekly basis I am confronted by the question of whether I should be giving a patient Sipuleucel T. I still use it, but not in all my CRPC patients, and I like to think of this therapy as having a reasonable benefit for patients - who are at an early point in the CRPC spectrum. I will explain but first let’s review the data and its limitations.
My first book, The Virility Paradox,  came out in February. I have written about it before and an interview with me ( by UCSD Urologist Kelly Parsons) has been posted elsewhere on UroToday. It has been a four year project and, perhaps a bit melodramatically, I’ll use an overused word and call it a four year ‘journey’. Here I want to focus on how that process changed me as a physician and affected my care of patients. Hopefully, there’s a lesson here for other clinicians and patients.
The ASCO Genitourinary Cancers Symposium for 2018 will feature the presentation of two-phase III studies of AR directed therapy in patients with non-metastatic CRPC. Before we get these results we can reflect on why these two studies were done in this patient population in the first place, and what exact clinical need is being addressed by the development of the studies in this space. 
If you treat mCRPC you need to know about mismatch repair. I don’t say this often, but it could be a matter of life or death. And that is not an exaggeration.

Ok, now that I have your attention, let’s talk about the science, the clinical care and the implications for the field.

But first, a brief case. Consider my patient Arnold (not his real name). He is a 68-year old man who underwent radical prostatectomy in 2011.
Late last November Bayer issued a press release notification of the premature halting of a study in which abiraterone and prednisone plus radium 223 was being compared to abiraterone and prednisone alone (ERA 223, NCT02043678). The announcement revealed that the study was being terminated early due to an imbalance in fractures and survival between the two arms – favoring the control arm
Brief high-level review of the LATITUDE and STAMPEDE Studies

LATITUDE was a phase III trial of men with high-volume metastatic prostate cancer (PC) that had not been previously treated with androgen deprivation therapy (ADT).1 The patients were randomized to receive standard ADT with placebos vs. ADT plus abiraterone and prednisone. The primary endpoint is overall survival (OS).
One of the biggest misconceptions in all of cancer care and oncology is the notion that a solid tumor ‘recurs’ after local therapy. If, as is often stated, ‘we got it all’ during surgery, then how can a cancer recur? The answer of course is that it was there all along. But that’s only the beginning of the story.

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