Real-World Treatment Patterns in Metastatic Hormone-Sensitive Prostate Cancer in the US - Umang Swami
April 1, 2025
Neeraj Agarwal speaks with Umang Swami about treatment patterns in metastatic hormone-sensitive prostate cancer (mHSPC). Dr. Swami presents encouraging findings from a large retrospective study using the Flatiron Health database of 14,000 patients showing that ADT intensification therapies have risen dramatically from just 40% a few years ago to 77% since January 2023. The data reveals that approximately 65% of patients now receive ADT with androgen receptor pathway inhibitors (ARPIs), while 10-15% receive triplet therapy (ADT+ARPI+docetaxel), with only about 17% still receiving ADT monotherapy. This represents the first large-scale study evaluating current treatment patterns, with most data coming from community oncology practices rather than academic centers. Dr. Agarwal notes that while this represents significant progress in guideline-concordant care, further work remains as additional novel therapies emerge for specific molecular subtypes of mHSPC.
Biographies:
Umang Swami, MD, Assistant Professor in the Division of Oncology, Department of Internal Medicine at Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
Neeraj Agarwal, MD, FASCO, Professor, Presidential Endowed Chair of Cancer Research, Director GU Program and the Center of Investigational Therapeutics (CIT), Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
Biographies:
Umang Swami, MD, Assistant Professor in the Division of Oncology, Department of Internal Medicine at Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
Neeraj Agarwal, MD, FASCO, Professor, Presidential Endowed Chair of Cancer Research, Director GU Program and the Center of Investigational Therapeutics (CIT), Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
Read the Full Video Transcript
Neeraj Agarwal: Welcome to another UroToday episode. Here we have Dr. Umang Swami, who is a faculty in oncology division at the Huntsman Cancer Institute at the University of Utah, who is an esteemed colleague of mine. And I am Neeraj Agarwal, a professor of medicine and director of Genitourinary Oncology program. And I have the honor of working closely with Doctor Umang Swami here.
So we'll be discussing the abstract, you present, Umang, at the 2025 ASCO GU meeting on the recent treatment patterns in patients with metastatic hormone-sensitive prostate cancer. And you showed the most encouraging piece of data we have been waiting to hear for many years now, that finally, the use of ADT combination therapies or ADT intensification regimens have improved to a significant extent.
And a large majority of patients with metastatic hormone-sensitive prostate cancer are finally receiving ADT combination therapy, or ADT intensification therapy. We like to use the word "combination" because intensification may have a negative connotation from the patient's perspective. So let's talk about the data, Umang.
Umang Swami: Thanks, Neeraj, and UroToday for giving me this opportunity to present our study. I would like to present our study, entitled "Recent treatment patterns in US-based real-world patients with metastatic hormone-sensitive prostate cancer," which we recently presented at 2025 ASCO GU Cancer Symposium.
Androgen deprivation therapy intensification, defined as androgen deprivation therapy with androgen receptor pathway inhibitors with or without docetaxel, have shown to improve overall survival outcomes in patients with metastatic hormone-sensitive prostate cancer, or mHSPC, and is recommended as standard of care by all major guidelines.
However, multiple studies done by various people, including Dr. Heath, Dr. Freedland, us, have shown that there is a significant underutilization of ADT intensification. Most studies reveal approximately 40% ADT intensification in patients with mHSPC. And there are limited, updated, and large-scale studies on the use of ADT intensification beyond January 2023. So in this study, we aim to assess the treatment patterns of ADT intensification in real-world patients with mHSPC in the US, including data on those treated since January 2023.
This was an IRB-approved retrospective study. We used de-identified nationwide Flatiron Health electronic health record derived database. And we extracted patient-level data. This longitudinal database is collected nationwide from 280 US cancer clinics, which results in approximately 800 sites of care. And most of these centers are community-based practices and some academic medical centers. And the data is curated via technology-enabled abstraction.
The eligibility criteria for our study was diagnosis of mHSPC and availability of treatment information, which can be ADT with another line of therapy in mHSPC. The data cutoff date was May 31, 2024. Patients were diagnosed with metastatic disease between 2013 to 2024. Treatment patterns were summarized using frequencies and percentages. And all analyses were done using R version 4.4.2.
Of approximately 24,000 patients in the cohort, 14,000 patients met our eligibility criteria and were included in the analysis. The median age of the cohort was 72 years. Most of the patients in our cohort were white, non-Hispanic. Approximately 81% of the patients came from community practices. And approximately 50% of the patients had commercial health plan.
So as we can see in this graph, on the left side, the use of ADT monotherapy, which was approximately 78% in 2013 to 2017, has gradually decline to approximately 17% after January 2023. In the overall cohort, going from January 1, 2013 to May 15, 2024, approximately 57% received ADT monotherapy, while 38% received ADT intensification.
However, if we just concentrate from January 2023 onwards, approximately 77% with metastatic patients with metastatic hormone-sensitive prostate cancer received ADT intensification, which is a remarkable improvement.
To conclude, to our knowledge, this is the first and the largest study to evaluate the current use of ADT intensification. These data indicate a notable improvement in adoption of level 1 evidence. That is ADT intensification in treatment of patients with metastatic hormone-sensitive prostate cancer.
These encouraging data emphasize the benefits of continued effort to promote guidance, concordant care, and provide the current treatment landscape to design clinical trials. I would like to thank Dr. Agarwal and UroToday for this opportunity.
Neeraj Agarwal: So congratulations, Umang. These are really remarkable data showing that our patients with metastatic hormone-sensitive prostate cancer are increasingly being treated with what we call standard of care treatment now, which is ADT combination-based regimen or ADT intensification regimens.
Just 2 years ago, you showed less than 50% of our patients with mHSPC were getting these treatments. And now, this number of proportion of patients receiving ADT intensification regimens or ADT combination regimen has gone up to about 80%. 60% of them received ADT plus ARPI. And it was nice to see that ADT plus ARPI plus docetaxel use has also gone up to being used in about 20% of these patients.
And the best news I saw was about 10% or less of these patients are receiving ADT monotherapy. I think this is very encouraging overall. Before I move forward, I'd like to ask you about the database and what kind of clinics are usually included in the Flatiron. Are these urologic clinics? Are these medical oncology clinics, or both? So let's start with the database you used for this study.
Umang Swami: Thanks, Neeraj. Yes, I agree. It's very encouraging to see that the practice-changing data from clinical trials is being translated in our clinical practice. To go and to dwell in the data set, we used Flatiron Health electronic health record-based data set.
And this data set is a longitudinal data set, which collects data from 280 US-based cancer clinics and approximately 800 sites of care. So this is a pure US-based data set. And most of these cancer centers from which the data is collected are community-based practices.
So this data, which is being shown, is being presented, is mainly derived from community practices, not academic practices, though academic centers are also part of it, but majority are community practices. And this data is curated by technology-enabled abstraction. And some natural language processing is also utilized in this data extraction.
Neeraj Agarwal: Just for our viewers, Flatiron is extracting these data directly from the electronic medical record and is not affected by the recall bias or recollection bias, if you will.
Umang Swami: Yes, and these data are being extracted from oncology notes. So most of these patients are being treated by oncologists. And these are oncology-based practices.
Neeraj Agarwal: Yeah. So these are a really large number of patients-- 14,000-plus patients, mostly from medical oncology clinics in the community setting. Right?
Umang Swami: Yes.
Neeraj Agarwal: Now, the second part is the ADT plus ARPI combination. So what was the uptake you have seen, which is how much it has improved since 2023?
Umang Swami: So if we look at our data set, we have also presented the same data in 2020. Basically, at that time, the use of ADT with androgen receptor pathway inhibitors was quite low. Approximately only 40% of the patients were receiving ADT intensification. And at that time, approximately 60% of the patients were receiving ADT monotherapy.
So from that time onwards, there has been a significant uptake of ADT with androgen receptor pathway inhibitors. And mostly after 2023, January 2023, we are seeing that approximately 65% of the patients are receiving ADT with androgen receptor pathway inhibitors. And then a 10% to 15% of the patients are receiving triplet therapy, which is androgen deprivation therapy with androgen receptor pathway inhibitors with docetaxel.
Neeraj Agarwal: Definitely much better uptake of ADT combination therapies, either with ARPI or ARPI plus docetaxel in our patients. And these are medical oncology clinics out there in the community setting, which is another fantastic news. Now, there are still patients who are receiving ADT monotherapy-- about 10% to 15% of these patients. Who are these patients?
Umang Swami: Neeraj, that's a very good question. We will be looking at these patients' baseline characteristics in our upcoming publication. Basically, I feel that maybe these patients are having multiple comorbidities, or they may be having some other social disparities or different insurance due to which they might not be having access to intensified treatment.
Neeraj Agarwal: That brings me to the next question of insurance. Was insurance playing a role-- Medicaid, Medicare, commercial insurance, other insurances? There are so many out there. Were they playing a role in how these patients are receiving triplet therapy versus doublet therapy or ADT plus ARPI versus ADT plus ARPI plus docetaxel versus ADT monotherapy?
Umang Swami: Neeraj, again, this is a very excellent question. And we are looking at these nuances to identify what are the reasons one treatment is being preferred over another, whether there is an insurance issue, whether there is an issue with regards to comorbidities, age, or location. So these things we are currently exploring in the data set.
Neeraj Agarwal: Umang, thank you for presenting these data. Really encouraging piece of data showing now that up to 80% of our patients with metastatic hormone-sensitive prostate cancer are receiving standard of care ADT combination-based regimens, either with ADT plus ARPI or ADT plus ARPI plus docetaxel. And only a small number of patients, about 10% to 15% of our patients with mHSPC are receiving ADT monotherapy only.
I think the work doesn't stop here. It is definitely very encouraging to see these combination regimens now used in vast majority of patients, but as we know, many more trials will be reporting in the near future, including PSMAddition trial with lutetium-177-based therapy in metastatic hormone-sensitive prostate cancer.
We'll be seeing two PARP inhibitor-based trials in patients with homologous recombination repair deficiency in their tumors, the TALAPRO-3 trial, and then AMPLITUDE trial using talazoparib and niraparib. And then we recently saw the press release from the CAPItello trial showing improved radiographic progression-free survival. The trial met the primary endpoint in patients who were treated with capivasertib and AKT inhibitor in patients with PTEN-deficient tumors.
So work has not stopped. Now, next level of work will be how to improve utilization of these further novel regimens in our patients. Having said that, I really want to congratulate you for this excellent work using the Flatiron database. And definitely fantastic news for our patients and for providers across the world.
Umang Swami: Thank you, Neeraj, and thanks to UroToday for this opportunity.
Neeraj Agarwal: Thank you for being here today.
Neeraj Agarwal: Welcome to another UroToday episode. Here we have Dr. Umang Swami, who is a faculty in oncology division at the Huntsman Cancer Institute at the University of Utah, who is an esteemed colleague of mine. And I am Neeraj Agarwal, a professor of medicine and director of Genitourinary Oncology program. And I have the honor of working closely with Doctor Umang Swami here.
So we'll be discussing the abstract, you present, Umang, at the 2025 ASCO GU meeting on the recent treatment patterns in patients with metastatic hormone-sensitive prostate cancer. And you showed the most encouraging piece of data we have been waiting to hear for many years now, that finally, the use of ADT combination therapies or ADT intensification regimens have improved to a significant extent.
And a large majority of patients with metastatic hormone-sensitive prostate cancer are finally receiving ADT combination therapy, or ADT intensification therapy. We like to use the word "combination" because intensification may have a negative connotation from the patient's perspective. So let's talk about the data, Umang.
Umang Swami: Thanks, Neeraj, and UroToday for giving me this opportunity to present our study. I would like to present our study, entitled "Recent treatment patterns in US-based real-world patients with metastatic hormone-sensitive prostate cancer," which we recently presented at 2025 ASCO GU Cancer Symposium.
Androgen deprivation therapy intensification, defined as androgen deprivation therapy with androgen receptor pathway inhibitors with or without docetaxel, have shown to improve overall survival outcomes in patients with metastatic hormone-sensitive prostate cancer, or mHSPC, and is recommended as standard of care by all major guidelines.
However, multiple studies done by various people, including Dr. Heath, Dr. Freedland, us, have shown that there is a significant underutilization of ADT intensification. Most studies reveal approximately 40% ADT intensification in patients with mHSPC. And there are limited, updated, and large-scale studies on the use of ADT intensification beyond January 2023. So in this study, we aim to assess the treatment patterns of ADT intensification in real-world patients with mHSPC in the US, including data on those treated since January 2023.
This was an IRB-approved retrospective study. We used de-identified nationwide Flatiron Health electronic health record derived database. And we extracted patient-level data. This longitudinal database is collected nationwide from 280 US cancer clinics, which results in approximately 800 sites of care. And most of these centers are community-based practices and some academic medical centers. And the data is curated via technology-enabled abstraction.
The eligibility criteria for our study was diagnosis of mHSPC and availability of treatment information, which can be ADT with another line of therapy in mHSPC. The data cutoff date was May 31, 2024. Patients were diagnosed with metastatic disease between 2013 to 2024. Treatment patterns were summarized using frequencies and percentages. And all analyses were done using R version 4.4.2.
Of approximately 24,000 patients in the cohort, 14,000 patients met our eligibility criteria and were included in the analysis. The median age of the cohort was 72 years. Most of the patients in our cohort were white, non-Hispanic. Approximately 81% of the patients came from community practices. And approximately 50% of the patients had commercial health plan.
So as we can see in this graph, on the left side, the use of ADT monotherapy, which was approximately 78% in 2013 to 2017, has gradually decline to approximately 17% after January 2023. In the overall cohort, going from January 1, 2013 to May 15, 2024, approximately 57% received ADT monotherapy, while 38% received ADT intensification.
However, if we just concentrate from January 2023 onwards, approximately 77% with metastatic patients with metastatic hormone-sensitive prostate cancer received ADT intensification, which is a remarkable improvement.
To conclude, to our knowledge, this is the first and the largest study to evaluate the current use of ADT intensification. These data indicate a notable improvement in adoption of level 1 evidence. That is ADT intensification in treatment of patients with metastatic hormone-sensitive prostate cancer.
These encouraging data emphasize the benefits of continued effort to promote guidance, concordant care, and provide the current treatment landscape to design clinical trials. I would like to thank Dr. Agarwal and UroToday for this opportunity.
Neeraj Agarwal: So congratulations, Umang. These are really remarkable data showing that our patients with metastatic hormone-sensitive prostate cancer are increasingly being treated with what we call standard of care treatment now, which is ADT combination-based regimen or ADT intensification regimens.
Just 2 years ago, you showed less than 50% of our patients with mHSPC were getting these treatments. And now, this number of proportion of patients receiving ADT intensification regimens or ADT combination regimen has gone up to about 80%. 60% of them received ADT plus ARPI. And it was nice to see that ADT plus ARPI plus docetaxel use has also gone up to being used in about 20% of these patients.
And the best news I saw was about 10% or less of these patients are receiving ADT monotherapy. I think this is very encouraging overall. Before I move forward, I'd like to ask you about the database and what kind of clinics are usually included in the Flatiron. Are these urologic clinics? Are these medical oncology clinics, or both? So let's start with the database you used for this study.
Umang Swami: Thanks, Neeraj. Yes, I agree. It's very encouraging to see that the practice-changing data from clinical trials is being translated in our clinical practice. To go and to dwell in the data set, we used Flatiron Health electronic health record-based data set.
And this data set is a longitudinal data set, which collects data from 280 US-based cancer clinics and approximately 800 sites of care. So this is a pure US-based data set. And most of these cancer centers from which the data is collected are community-based practices.
So this data, which is being shown, is being presented, is mainly derived from community practices, not academic practices, though academic centers are also part of it, but majority are community practices. And this data is curated by technology-enabled abstraction. And some natural language processing is also utilized in this data extraction.
Neeraj Agarwal: Just for our viewers, Flatiron is extracting these data directly from the electronic medical record and is not affected by the recall bias or recollection bias, if you will.
Umang Swami: Yes, and these data are being extracted from oncology notes. So most of these patients are being treated by oncologists. And these are oncology-based practices.
Neeraj Agarwal: Yeah. So these are a really large number of patients-- 14,000-plus patients, mostly from medical oncology clinics in the community setting. Right?
Umang Swami: Yes.
Neeraj Agarwal: Now, the second part is the ADT plus ARPI combination. So what was the uptake you have seen, which is how much it has improved since 2023?
Umang Swami: So if we look at our data set, we have also presented the same data in 2020. Basically, at that time, the use of ADT with androgen receptor pathway inhibitors was quite low. Approximately only 40% of the patients were receiving ADT intensification. And at that time, approximately 60% of the patients were receiving ADT monotherapy.
So from that time onwards, there has been a significant uptake of ADT with androgen receptor pathway inhibitors. And mostly after 2023, January 2023, we are seeing that approximately 65% of the patients are receiving ADT with androgen receptor pathway inhibitors. And then a 10% to 15% of the patients are receiving triplet therapy, which is androgen deprivation therapy with androgen receptor pathway inhibitors with docetaxel.
Neeraj Agarwal: Definitely much better uptake of ADT combination therapies, either with ARPI or ARPI plus docetaxel in our patients. And these are medical oncology clinics out there in the community setting, which is another fantastic news. Now, there are still patients who are receiving ADT monotherapy-- about 10% to 15% of these patients. Who are these patients?
Umang Swami: Neeraj, that's a very good question. We will be looking at these patients' baseline characteristics in our upcoming publication. Basically, I feel that maybe these patients are having multiple comorbidities, or they may be having some other social disparities or different insurance due to which they might not be having access to intensified treatment.
Neeraj Agarwal: That brings me to the next question of insurance. Was insurance playing a role-- Medicaid, Medicare, commercial insurance, other insurances? There are so many out there. Were they playing a role in how these patients are receiving triplet therapy versus doublet therapy or ADT plus ARPI versus ADT plus ARPI plus docetaxel versus ADT monotherapy?
Umang Swami: Neeraj, again, this is a very excellent question. And we are looking at these nuances to identify what are the reasons one treatment is being preferred over another, whether there is an insurance issue, whether there is an issue with regards to comorbidities, age, or location. So these things we are currently exploring in the data set.
Neeraj Agarwal: Umang, thank you for presenting these data. Really encouraging piece of data showing now that up to 80% of our patients with metastatic hormone-sensitive prostate cancer are receiving standard of care ADT combination-based regimens, either with ADT plus ARPI or ADT plus ARPI plus docetaxel. And only a small number of patients, about 10% to 15% of our patients with mHSPC are receiving ADT monotherapy only.
I think the work doesn't stop here. It is definitely very encouraging to see these combination regimens now used in vast majority of patients, but as we know, many more trials will be reporting in the near future, including PSMAddition trial with lutetium-177-based therapy in metastatic hormone-sensitive prostate cancer.
We'll be seeing two PARP inhibitor-based trials in patients with homologous recombination repair deficiency in their tumors, the TALAPRO-3 trial, and then AMPLITUDE trial using talazoparib and niraparib. And then we recently saw the press release from the CAPItello trial showing improved radiographic progression-free survival. The trial met the primary endpoint in patients who were treated with capivasertib and AKT inhibitor in patients with PTEN-deficient tumors.
So work has not stopped. Now, next level of work will be how to improve utilization of these further novel regimens in our patients. Having said that, I really want to congratulate you for this excellent work using the Flatiron database. And definitely fantastic news for our patients and for providers across the world.
Umang Swami: Thank you, Neeraj, and thanks to UroToday for this opportunity.
Neeraj Agarwal: Thank you for being here today.