Identifying Which Patients Benefit From Cabazitaxel for mCRPC

Edwin M. Posadas, MD

Medical Director, Urologic Oncology Program

Samuel Oschin Comprehensive Cancer Institute

Clinical Co-Chief

Associate Professor of Medicine

Division of Hematology/Oncology

Department of Medicine

Cedars-Sinai

DISCUSSION QUESTIONS:

• Have the CARD trial (NCT02485691) data influenced your practice? ​
• What is your approach in managing toxicities associated with cabazitaxel (Jevtana)?​
• How do you counsel patients who may receive cabazitaxel? ​
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EDWIN M. POSADAS, MD: This was an important study for us as a field because it gave us some evidence about what we can and shouldn’t do in this setting. I think the class switching was a favorite thing to do for concerns about toxicity. A lot of us had experience with moving patients, even back in the day, from things like bicalutamide to nilutamide and getting responses. We have things like survival and good PFS data to guide those decisions.

MICHAEL SCHWEIZER, MD: I think it definitely refocused attention on cabazitaxel as an important option for patients that have already progressed on docetaxel and a prior androgen receptor [AR]­–signaling inhibitor. I think in some ways using a second taxane isn’t the [most exciting option] to do for your patient second line, but these data show that there’s an objective benefit with this drug.1

There’s no huge difference in terms of overall quality of life doing an AR inhibitor versus cabazitaxel.2 That probably reflects that you’re using a more active agent. I sometimes do the class switch. Probably the most frequent situation is for a patient who’s slowly transitioning from abiraterone in the hormone-sensitive space to castration resistance. [A patient who is] asymptomatic with a low PSA [prostate-specific antigen] is not the patient [type] that went on the CARD trial. The patients who went on this were very high risk. They already progressed on chemotherapy. Most of them had pain at the time of enrollment. PSA is around 50 ng/mL or higher. These are patients with serious disease that need something to get it under control, otherwise they’re heading towards hospice most likely. I think this is a good agent for a lot of those patients.

AMIR MODARRESSI, MD: The classic scenario is that patients who go on cabazitaxel are patients who show disease progression on docetaxel because these patients, at least in community practice, have already exhausted all the endocrine options. It’s interesting to see that the quality of life can potentially improve, despite giving the patient second-line toxic therapy. All of these patients are pancytopenic, oftentimes transfusion dependent by now, and need growth factor support. [You need a] good discussion with the patient, establishing goals of care. A lot of these patients tolerate chemotherapy, and why not extend their survival if they can?

SCHWEIZER: That’s a good point, and I always bring that up with my patients, too. You get a lot of hesitancy about using back-to-back chemotherapy regimens just because of the toxicity, but the quality-of-life data are important to patients and they want to see that it’s not going to make them feel horrible for the last part of their life. In fact, if you get the disease under control, they might have some good time left.

_References:

_{1. de Wit R, de Bono J, Sternberg CN, et al. Cabazitaxel versus abiraterone or enzalutamide in metastatic prostate cancer. N Engl J Med. 2019;381(26):2506-2518. doi:10.1056/NEJMoa1911206}

_{2. Fizazi K, Kramer G, Eymard JC, et al. Quality of life in patients with metastatic prostate cancer following treatment with cabazitaxel versus abiraterone or enzalutamide (CARD): an analysis of a randomised, multicentre, open-label, phase 4 study. Lancet Oncol. 2020;21(11):1513-1525. doi:10.1016/S1470-2045(20)30449-6}