Buenos Aires, Argentina (UroToday.com) Fred Saad, Professor University of Montreal, presented a thorough review of AR variants and in particular AR-V7 in the management of patients with metastatic castrate-resistant prostate cancer (mCRPC). Issues to consider include mCRPC is incurable and lethal, we don’t know sequence of therapy and ADT may not be best approach for everyone. Evidence suggests we have hormone sensitive clones and hormone insensitive clones. Management of insensitive clones have been proven in CHAARTED and STAMPEDE trials. Overall survival is dismal when chemotherapy is administered late versus early as seen in CHARTED. Moreover, not all mCRPC patients are equal with need to incorporate prognostic factors (LDH, sites of metastases, ECOG status) when determining treatments and in whom. Visceral metastatic disease carries a particularly lethal diagnosis. AR targeted therapies are also more effective when given early in the disease course. When combining PSA, pain and Gleason score AR targeted agents are superior when all three are low. Chemotherapy may be less effective after ADT and/or AR targeted agents. CTC AR-V7 status has important implications when discerning whether chemotherapy versus AR targeted therapies are administered and in which sequence. However, AR-V7 status is dynamic and not static and may change pending treatments. Hormone therapy should be considered in the majority and it may be argued to consider chemotherapy upfront in younger healthier patients. At my institution, we individualize patient treatments taking into account the aforementioned predictors.
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Written By: Stephen B. Williams, M.D., Assistant Professor in Urology, The University of Texas Medical Branch, Galveston, TX. and Ashish Kamat, M.D. Professor, Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.