ASCO GU 2019: Quality of Life-Focused Decision-Making for Castrate-Sensitive Prostate Cancer

San Francisco, CA (UroToday.com) Dr. Alicia Morgans presented data on quality of life (QOL) focused decision-making, in the context of castrate-sensitive prostate cancer. However, as she noted, many of these principles can, and should be, broadly applied to all disease states within genitourinary oncology.

The first patient case presented was a 62 year old man who presents for the first time with a PSA 87 and back pain, found to have a new diagnosis of metastatic prostate cancer. In this patient with metastatic castration-sensitive prostate cancer (mCSPC), and in that case, many oncology patients, there are two different viewpoints to consider:
  1. Physician – In the physician’s mind, they have labeled this patient as mCSPC, high-risk (by LATITUDE criteria), high-volume (by CHAARTED criteria), and with good ECOG PS 1.
  2. Patient – however, the patient is thinking about the following:
         a. Can I still work?
         b. Will the treatment be painful?
         c. Will I be a burden on my family and loved ones?
         d. Can I care for my wife/spouse?
In a survey of 96 men with metastatic prostate cancer (Morgans A et al., AUA abstract 2017), Dr. Morgans team found that the 3 most important factors for patients is the following:
  1. Feeling well enough to spend time with family
  2. Being able to die in a manner consistent with one’s wishes
  3. Being presented with treatment choices
Treatment “effectiveness” is not one of those!

There are 3 types of decision-making, highlighted well below:
Quality of Life Focused Decision Making for Castrate Sensitive Prostate Cancer
Of these, only the third “shared decision making”, involves flow of information in both directions. This has already been adopted in the low risk prostate cancer discussion, and should be adopted in the advanced prostate cancer disease space.

What are this patient’s options? He has many, according to the NCCN – and more options are likely to be available soon, based on data to be presented. These include: ADT alone, orchiectomy, ADT + docetaxel, ADT + abiraterone, or watchful waiting.

Part of the decision making should take into account QOL – as many of these treatments are not curative, it is imperative to consider patient QOL at potential end-of-life. As she points out though, QOL is not defined by adverse events alone, as some clinical trials would suggest. 

Rather, she suggests that QOL takes into account symptomatic adverse events, but also patient-reported outcomes and an “x-factor” that is harder to define (image below)
Quality of Life Focused Decision Making for Castrate Sensitive Prostate Cancer picture2

Adverse events are defined by the “Common Terminology Criteria for Adverse Events” or CTCAE, which has helped to standardize reporting across publication. PROs (patient reported outcomes) are patient experiences reported by PROs measures, such as the FACT-P. These must be validated and reliable. However, once validated and reliable, they are invaluable for subjective symptoms and can detect up to 50% more symptoms than clinician assessment alone.

Using this basis, she assessed the two main options for this patient chemohormonal therapy (ADT+Docetaxol) or Abiraterone+ADT, both of which are considered the standard of care. Dr. Morgans reviews the data from the main studies that led to their utilization.

  1.  ADT+Docetaxl – supported by the CHAARTED (Sweeney C, et al. NEJM) and STAMPEDE (James N, et al. Lancet 2016) trials.
Focusing on the CHAARTED data, FACT-P assessments were taken of patients during the trial. Using a mixed effects model, they found that scores were worse in the Docetaxel arm during active treatment, but were better than placebo at 12 months.
Quality of Life Focused Decision Making for Castrate Sensitive Prostate Cancer picture3
      2. ADT+Abiraterone – supported by LATITUDE (Fizazi et al., NEJM) and STAMPEDE (James N. et al, NEJM).

In the LATITUDE study, they also used a FACT-P assessment but the time of assessment was different and the model to analyze was different. However, the outcomes were similar and patients fared better with Abi+ADT than with ADT alone.
Quality of Life Focused Decision Making for Castrate Sensitive Prostate Cancer picture 4
The challenge, therefore, is that even though the same instrument was used, analysis and presentation of data was very different. Standardization of method of analysis and presentation is critical.

In closing, the “X-factor,” needs to be worked on and these include issues such as: how many additional clinic visits, financial toxicity, how long will treatment take, how does the treatment affect ability to work or care for family? Ultimately, in this situation, the best option depends on the patient – not the disease!

Presented by: Alicia K. Morgans, MD, MPH - Northwestern University 

Written by: Thenappan Chandrasekar, MD (Clinical Instructor, Thomas Jefferson University) (twitter: @tchandra_uromd, @JEFFUrology) at the 2019 American Society of Clinical Oncology Genitourinary Cancers Symposium, (ASCO GU) #GU19, February 14-16, 2019 - San Francisco, CA