Advances in Treatment for Metastatic Hormone Sensitive Prostate Cancer: With so many options, can we really go wrong?

Alicia Morgans | September 05, 2019

As we all look forward to another prostate cancer awareness month, I find myself reeling with the advances the field has seen in the past year, particularly in the area of hormone sensitive metastatic prostate cancer. We learned that men may live longer if we can radiate the primary tumor if they have low volume metastatic disease. We also learned that enzalutamide and

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Alicia Morgans, MD

Alicia Morgans, MD, MPH is an Associate Professor of Medicine in the Division of Hematology/Oncology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois. She is a clinician and physician investigator specializing is investigating complications of systemic therapy for prostate cancer survivors. She has expertise in clinical trials and patient reported outcome measures, and as well as incorporating patient preferences and beliefs into clinical decision making.

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Everyday Urology - Oncology Insights
Publications focusing on urologic cancer treatments through original manuscripts
By Phillip J Koo, MD
Imaging in prostate cancer (PC) remains a controversial topic that can be challenging to navigate. In this article, I focus on some of the best tools in our current armamentarium: multiparametric prostate magnetic resonance imaging (mpMRI) for local prostate cancer (PC) and positron emission tomography-computed tomography (PET/CT) for advanced disease. In research settings, these modalities often overlap, but here I take a more practical approach by focusing on the use of PET/CT for the detection of metastatic disease.
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Evidence based monographs by experts to define and guide clinical practice
Written by Zachary Klaassen, MD, MSc, and Christopher J.D. Wallis, MD, Ph.D

In the United States and Europe, prostate cancer is the second most common malignancy and the second leading cause of cancer mortality among men1. While approximately 3% of men in the United States present with metastatic disease2, higher rates are experienced globally3. For the past 70 years, androgen deprivation therapy (ADT) has been the mainstay of therapy for locally advanced or metastatic disease, considering that the androgen receptor (AR) pathway is critical for prostate cancer progression4. While the majority of patients will benefit from a biochemical and clinical response to ADT, most eventually develop castrate-resistant prostate cancer (CRPC) despite castrate levels of testosterone5. In the absence of new treatment options, for nearly twenty years, there had been no appreciable improvement in survival among men diagnosed with metastatic hormone-sensitive prostate cancer6. Since 2004, there has been considerable progress in the treatment options and outcomes for men with castrate-resistant prostate cancer, as summarized in the UroToday Center of Excellence article entitled “Evidence-Based Therapeutic Approaches for mCRPC”. However, only since 2016, has there been evidence-based treatment options with proven survival benefit for men with metastatic hormone-sensitive prostate cancer, also known as metastatic castrate sensitive or hormone naïve disease.

 

Written by Zachary Klaassen, MD, MSc
Metastatic hormone-sensitive prostate cancer (mHSPC) is the disease space whereby men have metastatic prostate cancer and have never received (ie. are sensitive to) androgen deprivation therapy (ADT). mHSPC previously constituted ~30% of prostate cancer cases,1 however, from 2004-2012 secondary to PSA testing, the estimate was ~5% of cases.2 Many experts in the field suggest that with decreased PSA screening over the last few years, as a result of the United States Preventative Services Task Force (USPSTF) Grade D recommendation for PSA screening (subsequently upgraded to C 3), that these estimates are likely to once again increase.4 Typically, these patients have been treated with ADT alone, at which point the clock begins ticking towards a castration-resistant time point and eventual mortality. Since 2015, we have seen several landmark trials published that have added therapies to ADT for these men, favorably impacting overall survival. This article will discuss the effect of docetaxel and abiraterone therapy among men with mHSPC and review the subsequent literature following reporting of these trials.
Conference Coverage
Recent data from conferences worldwide
Presented by Paul L. Nguyen, MD
Barcelona, Spain (UroToday.com) Dr. Nguyen presented a summary of the latest news in the treatment of metastatic hormone-sensitive prostate cancer (mHSPC). Four recent major trials were summarized and discussed in this presentation.
Presented by Silke Gillessen, MD
Barcelona, Spain (UroToday.com) Dr. Silke Gillessen presented the medical oncologist’s perspective on the current and future treatment of prostate cancer. Her talk mainly focused on the role of systemic therapy in metastatic hormone-sensitive prostate cancer (HSPC).
Presented by Andrew J. Armstrong, MD
San Francisco, CA (UroToday.com) The introduction of androgen-axis targeted therapies has drastically altered the landscape of advanced prostate cancer. Abiraterone acetate (AA) and Enzalutamide (ENZA) have been driving the change, and have been utilized in even earlier stages of advanced prostate cancer.
Presented by Neil Rohit Parikh, MD, MBA
San Francisco, CA (UroToday.com) Dr. Parikh discussed that previously published data have suggested there may be a benefit for metastasis-directed therapy in patients with oligorecurrent hormone-sensitive prostate cancer. 
Presented by Robert J. Hamilton, MD, MPH, FRCSC
Toronto, Ontario (UroToday.com) Dr. Robert Hamilton presented on the role of treatment of the primary tumor in the setting of metastatic hormone-sensitive prostate cancer (mHSPC).  He began his discussion providing the rationale for treating the primary tumor in mHSPC patients.
Presented by Ulka N. Vaishampayan, MD
Munich, Germany (UroToday.com) Enzalutamide is an androgen signaling inhibitor which prevents androgen receptor nuclear translocation and DNA binding, therefore leading to cellular apoptosis.
Presented by Celestia Higano, MD
Chicago, IL (UroToday.com) Celestia Higano, MD, gave an excellent talk on the topic of treatment toxicities in patients with metastatic hormone-sensitive prostate cancer (MHSPC). Dr. Higano began with the most important question in this topic, on how to decide which therapy to use in MHSPC. 
Presented by Neeraj Agarwal, MD
Chicago, IL (UroToday.com) Neeraj Agarwal provided a comprehensive overview of the treatment of mHSPC. Three general topics were reviewed – the current standard of care for men with (mHSPC), the role of definitive therapy of primary prostate cancer in the setting of mHSPC, 
Presented by Ulka Vaishampayan, MD
San Francisco, CA (UroToday.com) Dr. Vaishampayan and colleagues presented results of their randomized trial assessing enzalutamide vs bicalutamide in combination with androgen deprivation in metastatic hormone sensitive prostate cancer. 
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