Dr. Hwang on Choosing Agents for Prostate Cancer Treatment

Clara Hwang, MD, a medical oncologist with Henry Ford Health System, discusses factors that can be used to decide what agent to use in the frontline setting for patients with metastatic castration-sensitive or castration-resistant prostate cancer.

When deciding what agent to use in the frontline setting, high-risk or high-volume disease can be used as an indicator, explains Hwang. Enzalutamide (Xtandi), abiraterone acetate (Zytiga), and apalutamide (Erleada) appear to have benefits regardless of the volume of disease. “High-volume” was first defined by the CHAARTED trial; patients were classified as having high-volume disease if they had visceral disease or ≥4 bone metastases, 1 of which had to be extra-axial.

Patients with high-volume disease appeared to gain more benefit from docetaxel compared with patients with low-volume disease, a fact that could help decide between a novel antiandrogen and docetaxel, according to Hwang.

However, that idea about docetaxel is controversial, says Hwang. An updated analysis of STAMPEDE showed that docetaxel may be beneficial regardless of disease burden. Additionally, investigators reported that the addition of radiation may improve survival in patients with low-volume disease. The volume of disease, whether in a patient with oligometastases or visceral metastases, could potentially help physicians choose which treatment is most appropriate for their patients, concludes Hwang.