Dr. Wee on the Current Landscape of Nonmetastatic CRPC Treatment and Classification

Christopher Wee, MD, Department of Hematology and Medical Oncology, Cleveland Clinic, discusses the current treatment landscape for nonmetastatic castration-resistant prostate cancer (CRPC), and how the success of new diagnostic tools decreases the need for this classification.

The National Comprehensive Cancer Network currently recommends 3 category 1 treatments for administration alongside androgen deprivation therapy (ADT): darolutamide (Nubeqa), apalutamide (Erleada), and enzalutamide (Xtandi). All 3 drugs have shown improved metastasis-free survival and overall survival when compared with placebo. However, the efficacy of these treatments has not been evaluated head-to-head, so a definitive statement on their relative superiority cannot be made at this time. Instead, clinicians should consider factors such as other medications, patient preference, and comorbidities before deciding on a treatment strategy.

Although the use of these agents improves outcomes in this population, the prevalence of nonmetastatic CRPC classification appears to be decreasing, Wee continues. This can be attributed to shifts in treatment initiation and advances in imaging modalities. Many patients with hormone-sensitive biochemical recurrence, or nonmetastatic disease that is hormone sensitive, are not treated immediately. This reduces the use of ADT for castration, and thus the chance of developing castration resistance.

Furthermore, the use of imaging modalities, such as prostate-specific membrane antigen PET scans allow clinicians to diagnose patients who previously would have received a diagnosis of nonmetastatic CRPC as having metastatic disease, Wee concludes.