Choosing treatment for hormone-sensitive PCa: Key questions

Christopher Sweeney, MBBS, of Dana Farber Cancer Institute and Harvard Medical School in Boston, outlines a handful of important questions to ask when deciding which systemic therapy to select for which patient with metastatic hormone-sensitive prostate cancer.

What questions should clinicians consider when choosing a systemic therapy for a patient with hormone-sensitive prostate cancer?

What I've laid out is the spectrum of the treatment options, their associated benefits, and the patient population, including whether they're chemo fit and whether they are frail and elderly. The first thing we as physicians should ask is, are they chemo fit? What's the volume of their disease? And then, what might be the treatment options for that patient? Then offer the patient the treatments that may be suitable for them, and go through the side-effect profile and ask what is going on in their life that they may choose one therapy versus another.

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Let's start with the chemo-fit patient with a poor prognosis/high-volume disease. Some patients may say, "I really want to get the chemotherapy out of the way. It's cheaper, I know the side-effect profile, and it's done in 18 weeks. And when I'm done with that, I'm just on the shots every 3 months going forward." Other people might say, "I just don't like the idea of chemotherapy. I've got a very important event coming up, and chemo is just going to get in the way. I'd much prefer to go through the hormones at this stage." So I engage the patient in the decision.

Now if a patient is not chemo fit and has high-volume disease, abiraterone or apalutamide or enzalutamide are very reasonable. Someone with diabetes, you would steer away from abiraterone; someone with seizures, you would steer away from the amide drugs. So the decision is made around those factors.

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If the prostate is intact, the other thing to talk about is the addition of radiation to the prostate. If a patient has low-volume de novo metastatic disease, I will think about doing a hormone treatment, but testosterone suppression is the background--radiating the prostate and adding on either abiraterone or enzalutamide or apalutamide.

What’s the bottom line when talking to patients about this decision?

We've made significant strides since 2014. For the patient who is chemo fit, it's not either/or the hormones or the chemotherapy. It's chemotherapy now or chemotherapy later. That's another message to be clear about when we're speaking with patients. The bottom line is to engage the patient in the decision and go through the treatment options. Once the patient has made a decision with you, they're much more likely to understand what the risks and the benefits are, engage in the treatment, and have a better outcome.

Disclosures: Dr. Sweeney is a compensated consultant for Amgen, Astellas, Bayer, Genentech/Roche, Janssen, Pfizer, Celgene, Sanofi, and Lilly; is the founder of Leuchemix (with stock); and receives research funding from Astellas, Bayer, Janssen, Sanofi, and Dendreon.