David Morris, MD, FACS, practicing urologist, Advanced Therapeutics Center, Urology Associates of Nashville, discusses the best practices for active surveillance in low- and intermediate-risk patients with prostate cancer, highlighting factors to look for in patients undergoing active surveillance that may point to the need for further treatment.

, Morris participated in a discussion on active surveillance in patients with prostate cancer that highlighted the enhanced adoption of this approach for appropriately selected low-risk patients within the field of urology. A growing consensus emphasizes the need for a continued collective effort to advocate for active surveillance among low-risk patients who stand to benefit the most by avoiding the adverse effects associated with certain prostate cancer therapies, Morris explains. In the intermediate-risk population, the oncologic focus shifts toward a model centered on shared decision-making with the patients, he states. This model involves weighing the benefits and limitations of delaying therapy against initiating aggressive upfront treatment, Morris adds.

Various tools, such as genomics and magnetic resonance imaging (MRI), play a pivotal role in refining risk assessment, thereby facilitating more tailored and appropriate shared decision-making discussions, he expands. Typically, prostate-specific antigen (PSA) kinetics will serve as initial metrics for many practitioners to determine the necessity for further confirmatory tests, such as MRIs or biopsies, Morris emphasizes. Treating patients for prostate cancer directly from a period of active surveillance solely based on PSA levels is not common practice because PSAlevels can be influenced by various factors, such as prostate size, and thus may be misleading, he states.

AR5 inhibitors are a potential strategy for managing prostate cancer in men under active surveillance, as they may reduce the effects of fluctuations in PSA levels, Morris continues. However, the consensus in the urology field leans more toward using changes in biopsy grades or significant alterations observed in MRI results as primary indicators to transition towardactive treatment, he concludes.

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David Morris, MD, FACS, discusses the best practices for active surveillance in low- and intermediate-risk patients with prostate cancer, highlighting factors to look for in patients undergoing active surveillance that may point to the need for further treatment.


Dr Morris on Active Surveillance in Low- and Intermediate-Risk Patients With Prostate Cancer

David Morris, MD, FACS, a urologist at Urology Associates, P.C., discusses overall survival (OS) data with apalutamide (Erleada) in prostate cancer.

Trials examining antiandrogen agents, such as apalutamide, in patients with nonmetastatic castration-resistant prostate cancer were initially powered for metastasis-free survival, says Morris. However, there has been a lot of interest regarding secondary outcomes with these agents, such as OS, explains Morris. The first round of data cuts from all trials showed a trend for OS, but did not reach any statistical significance.

At the 2019 ESMO Congress, updated data with apalutamide showed a further trend to significance but did not yet cross the P value that was required for statistical significance, says Morris. However, the trial favored active drug therapy versus placebo with a median follow-up of up to 41 months, therefore providing support for the idea that these agents will likely show OS benefit if they continue to be followed for enough events, concludes Morris.

David Morris, MD, FACS, discusses overall survival data with apalutamide in prostate cancer.

Dr. Morris on OS Data With Apalutamide in Prostate Cancer

David Morris, MD, FACS, a urologist at Urology Associates, P.C., discusses choosing the best agent to treat patients with nonmetastatic castration-resistant prostate cancer.

Three androgen receptor inhibitors—apalutamide (Erleada), enzalutamide (Xtandi), and darolutamide (Nubeqa)&mdash;have shown similar efficacy in terms of the primary analysis of metastasis-free survival (MFS), explains Morris. All agents have shown about a 2-year benefit in MFS until there is metastasis on imaging in high-risk patients with quickly progressing disease, who have previously been on androgen deprivation therapy and did not have any evidence of metastasis on conventional imaging, says Morris.

The safety profile of each drug will likely determine which drug is best for each patient. Specific exclusion criteria need to be examined, including seizure risk and the tolerance of the medication, according to Morris. Financial toxicity for the patient may also impact the choice, concludes Morris.

David Morris, MD, FACS, discusses choosing the best agent to treat patients with nonmetastatic castration-resistant prostate cancer.

Dr. Morris on Treatment Considerations for CRPC

David Morris, MD, FACS, a urologist at Urology Associates, P.C., discusses the safety profiles and common adverse events (AEs) related to the androgen receptor inhibitors apalutamide (Erleada), enzalutamide (Xtandi), and darolutamide (Nubeqa) for prostate cancer.

The safety profiles between apalutamide, enzalutamide, and darolutamide are nuanced and do not indicate a clear winner when choosing one to give a patient, explains Morris. All the agents are associated with increased fatigue, though it is stronger with enzalutamide and apalutamide.

Patients with a history of seizures are excluded from receiving enzalutamide due to early trial experience. For apalutamide, a rash signal is forefront. For the most part, those AEs are manageable, low-grade, and may not be a strong enough reason to avoid any of the drugs or discontinue treatment says Morris, adding that they can often be managed with active drug therapy, according to Morris.

It is challenging to compare apalutamide, enzalutamide, and darolutamide through the trials, says Morris, because they are all measured differently. For example, there are different time intervals for measuring and capturing AEs during the trial, concludes Morris.

David Morris, MD, FACS, discusses the safety profiles and common adverse events related to the androgen receptor inhibitors apalutamide, enzalutamide, and darolutamide for prostate cancer.

David Morris, MD, FACS

Articles

Dr Morris on Active Surveillance in Low- and Intermediate-Risk Patients With Prostate Cancer

Dr. Morris on OS Data With Apalutamide in Prostate Cancer

Dr. Morris on Treatment Considerations for CRPC

Dr. Morris on Safety Profiles of AR Inhibitors in Prostate Cancer