An expert oncologist outlines first-line treatment options for patients with metastatic castration-resistant prostate cancer (mCRPC).
Case: A 65-Year-Old Man With Prostate Cancer
Daniel J. George, MD: When I have a patient that is diagnosed with metastatic CRPC [castration-resistant prostate cancer], first-line treatment options are predicated on a couple of factors. The first is, what were their prior treatments. To be metastatic castrate-resistant, you’ve had to had androgen deprivation therapy. But in that earlier disease settings, patients could be also treated with several other therapies, from androgen receptor inhibitors or androgen biosynthesis inhibitors, to chemotherapies, to even investigational agents. These are important considerations in the selection of our first line for metastatic CRPC.
I like to also think about the disease burden that patients have and the disease course. If this is rapid progression from initial hormonal therapy to castration resistance, they’re much more likely to have a resistant biology to other hormonal manipulations. If this is somebody that has relatively slow progression and low-volume disease, they’re patients that may respond to additional hormonal manipulations, or even immunotherapies, like sipuleucel-t. These are some of my considerations.
Then the other end of the spectrum would be our symptomatic high-volume patients, patients like this gentleman that we presented, where painful bone metastases is a phenotypic characteristic of their disease and something that’s affecting their quality of life. It’s also highly prognostic, and it’s why we chose a cytotoxic therapy like docetaxel in this case. To me, those characteristics, what they had for prior therapies, the pace of disease and the volume and symptoms of disease, determines my approaches.
When I can, I’ll use secondary hormonal therapies as a frontline agent if they’ve not received that before, or if they received it in the past and had a break and had a very slow progression, this is a treatment of choice along with immunotherapy. If they’ve got more higher volume, symptomatic disease, and they’ve had that novel hormonal agent already, then I’m more likely to choose a cytotoxic therapy like chemotherapy or a radiopharmaceutical. Then if they haven’t had a novel hormonal agent yet in the metastatic castrate-resistant space, those are the patients where I feel good about starting a novel hormonal agent on them. We also consider clinical trials of course in this space, but where I feel confident they have a high likelihood of benefiting from that frontline novel hormonal agent.
Transcript edited for clarity.