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


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.

Clinical Conversations by Experts
Everyday Urology - Oncology Insights
Publications focusing on urologic cancer treatments through original manuscripts
By William Oh, MD
Published Date: December 2019

A 65-year-old man presents with skeletal pain. His PSA is 101 ng per mL, computed tomography (CT) reveals pelvic lymphadenopathy, a 99mTc bone scan shows extensive bone metastases, and prostate biopsy cores are interpreted as Gleason score 9 with intraductal features. The patient starts long-term androgen-deprivation therapy (ADT) and completes five cycles of docetaxel. His pain resolves. His PSA declines but remains persistently elevated at 2.6 ng per mL, so the decision is made to add enzalutamide, a next-generation androgen receptor (AR)-targeted therapy, to ADT.
By Alicia Morgans, MD, MPH

Published Date: December 2019

Metastatic hormone-sensitive prostate cancer (mHSPC) has become increasingly prevalent in the United States. Between 2009 and 2020, experts have projected a nearly 17% increase in the number of newly diagnosed mHSPC cases and a more than 18% increase in cases of mHSPC occurring after failure of local (curative-intent) treatment.1 This increase is likely multifactorial, reflecting changes in prostate-specific antigen (PSA) screening practices, the increased use of more sensitive imaging modalities, and other factors.2, 3

By Phillip J Koo, MD
Published Date: June 2018

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.
Library Resources
The State-of-the-Evidence in Brief Reviews by Experts
Written by Zachary Klaassen, MD, MSc, and Christopher J.D. Wallis, MD, Ph.D
November 19, 2019

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


Written by Hanan Goldberg MD, Department of Urology, SUNY Upstate Medical University, Syracuse, NY, USA
February 1, 2020
Prostate cancer (PCa) is the most common non-cutaneous malignancy in US men and the second most common cause of cancer-specific death.The American Cancer Society estimates that in 2019, approximately 174,650 new cases will be diagnosed, and 31,620 cancer-specific deaths will occur.2
Written by Zachary Klaassen, MD, MSc
April 16, 2019
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
Conference Coverage
Conference Highlights from Recent Conference Coverage
Presented by Arun Azad, MBBS, PhD, FRACP
Enzalutamide plus ADT is approved in the US and Europe to treat castration-resistant prostate cancer and was also recently approved for men with metastatic hormone-sensitive prostate cancer (mHSPC) in the US. In ARCHES, enzalutamide plus ADT reduced the risk of the primary endpoint of radiographic progression-free survival events (by 61%), and improved key secondary endpoints versus placebo plus ADT in men with mHSPC.
Presented by Alicia Morgans, MD, MPH 
In a stand-alone session at this year’s Society of Urologic Oncology (SUO) virtual annual meeting, titled Understanding the Evolving Treatment Landscape in Prostate Cancer: How to Leverage the Latest Advances and Strategies to Optimize Patient Outcomes,
Presented by Ian Davis, MBBS, PhD, FRACP, FAChPM
The 2020 Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP) Mini Annual Scientific Meeting featured a session on ANZUP trial updates, including an update of the critical Phase III ENZAMET trial provided by Drs. Ian Davis, Arun Azad, and Lisa Horvath.
Presented by Alicia Morgans, MD, MPH
In a session entitled “Sorting Through the Maze of Treatment Options for Metastatic Castration-Sensitive Prostate Cancer”, Dr. Alicia Morgans from Northwestern University presented a plenary talk discussing the treatment considerations for patients who received combination therapy for metastatic castration sensitive prostate cancer (mCSPC).
Presented by Neal D. Shore, MD, FACS
Dr. Shore from the Carolina Urologic Research Center presented a plenary talk discussing the multitude of hormonal treatment options for patients with metastatic castration sensitive prostate cancer (mCSPC). Dr. Shore began by highlighting data from Dr. Huggins seminal work demonstrating that prostate cancer is hormone dependent.
Presented by Neal D. Shore, MD, FACS
Treatment paradigms for patients with metastatic hormone-sensitive prostate cancer (mHSPC) have changed dramatically in the past 4 years. Before 2016, there were no agents with a demonstrated overall survival benefit in this disease space.
Presented by Alok Tewari, MD, PhD
San Francisco, California ( The second case in the challenging cases discussion was that of a 71-year-old man, a former smoker who suffers from hypertension,
Presented by Alicia Morgans, MD, MPH,
San Francisco, California ( As part of the Prostate Cancer Session at the 2020 American Society of Clinical Oncology Genitourinary Cancers Symposium
Presented by Christopher Sweeney, MBBS
Washington, DC ( Renowned medical oncologist Dr. Chris Sweeney provided an overview of the current landscape of metastatic castration sensitive prostate cancer
Presented by Markus Graefen, MD
Athens, Greece ( Markus Graefen, MD, gave an overview of the role of experimental metastases directed therapies in the era of proven life-prolonging drugs
Presented by Syed Adnan Ali, MBBS
Barcelona, Spain ( In the STAMPEDE study, low metastatic burden was determined to be predictive of overall survival (OS) benefit when radiation therapy (RT)
Presented by Martin R. Stockler, MBBS, MSc, FRACP
Barcelona, Spain ( ENZAmet is an international, cooperative group, randomized phase 3 trial. It recently showed that after a median follow-up of 34 months
Presented by Nicholas James, BSc, MB, BS, FRCP, FRCR, PhD
Barcelona, Spain ( Professor Nicholas James presented results from the STAMPEDE trial for the addition of docetaxel to first-line hormonal therapy for patients with
Presented by Paul L. Nguyen, MD
Barcelona, Spain ( 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 ( 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 ( 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 ( 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 Celestia Higano, MD
Chicago, IL ( 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 ( 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 ( 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.