Management Issues in Metastatic Prostate Cancer
Jad Chahoud, MD, MPH
Hospital and Institutional Affiliations
Assistant Member, Department of Genitourinary Oncology at Moffitt Cancer Center in Tampa, Florida
Question 1. ADT plus abiraterone and ADT plus docetaxel are the current standard-of-care for mCSPC, and apalutamide in September received FDA approval for this disease state. How would you decide which medication to use in patients with mCSPC?
In my practice, to choose between abiraterone or docetaxel, after extensive and detailed discussions with patients, we adapt our decision based on tumor volume, toxicity profile, and the ability to rechallenge with docetaxel in the hormone-resistant setting.
Question 2. How do you decide the optimal time to begin treatment for metastatic castration-sensitive prostate cancer (mCSPC)?
We always take into consideration patient factors, including goals of care, other medical conditions, and disease risk factors to decide on our treatment approach in metastatic castration-sensitive prostate cancer (mCSPC). With the approval of multiple androgen-blocking combinations that are safe and the availability of clinical trials, patients tend to start earlier on these combinations.
Question 3. What do you consider the major challenges in the management of metastatic PCa?
I think that the 2 major challenges that face patients diagnosed with advanced PCa would be the impact that the disease has on their quality of life and also the financial toxicity associated with the therapy.
Question 4. What do you see as the next big step forward in the pharmacotherapy of metastatic PCa?
I believe biomarker driven approaches will be the next step in the field to improve our drug selection and sequencing. Also, many drugs that target the DNA repair pathway could be receiving FDA approval in the near future.
Question 5. To what extent does the cost of the novel antiandrogens affect treatment decisions?
The impact of financial toxicity related to the diagnosis and treatment of prostate cancer is significant and impacts the life of all our patients. My colleague and prostate cancer expert Dr Jingsong Zhang has opened 2 investigator-initiated trials that are enrolling patients with a dose titration regimen of the novel combination of ADT with abiraterone. These studies aim to limit the financial and physical drug-related toxicities of these novel approved drugs.