Upfront chemo: Time to take notice

The “embarrassment of riches” of therapeutic options for advanced prostate cancer fortunately continues, encouraging us all to strive for lessening the incidence and impact of prostate cancer-specific mortality.

Dr. Shore is medical director of Carolina Urologic Research Center, Myrtle Beach, SC.

At this year’s ASCO annual meeting, dramatic results of a trial comparing “upfront” chemotherapy plus androgen deprivation therapy (ADT) versus ADT alone in men with metastatic prostate cancer were presented (see "Upfront chemo plus ADT dramatically improves survival"). A planned interim analysis of the trial, known by the acronym CHAARTED, met the criteria for overall survival (OS) significance.

Median OS was 57.6 months in the ADT plus docectaxel arm and 44.0 months in the ADT arm (p=.0003). Of note, the trial inclusion/exclusion criteria were expanded to lower volume patients due to slow accrual.

Perhaps now more progressive urology practices will not only consider infusing docetaxel and/or having enhanced dialogue with their medical oncology colleagues, but also become involved as trial sites to help answer unmet clinical questions regarding sequencing and combinatorial strategies of both oral and infusional therapies.

Furthermore, some urology practices with advanced prostate cancer specialization may want to explore educational initiatives for administering chemotherapy, in addition to other approved infusion therapies.

More important, even though ~4%-5% of newly diagnosed U.S. patients present with radiologically confirmed metastatic disease and the impact of this trial represents a small subset of the newly diagnosed patient population, the 17-month median OS supersedes other currently FDA-approved castration-resistant prostate cancer (CRPC) therapies by a factor of four- to fivefold.

The reported adverse event profile was lower than previously seen in CRPC trials (eg, TAX 327, SWOG 9916); of note, patients in these trials were older, had further disease progression, and had a presumably more aggressive disease phenotype.

It is now incumbent upon all who discuss therapeutic options with advanced prostate cancer patients to discuss the dramatic survival and disease progression advantages of this therapeutic combination. Some ongoing considerations might include: 1) a clinic’s retrospective review of “recent” newly diagnosed patients with metastatic disease, already initiated with ADT, and thus a present-day discussion for initiating six cycles of docetaxel; 2) awareness of updated data on patients with this trial’s low-volume disease cohort when available; 3) revised consideration for chemohormonal/combination trials for high-risk biochemical relapse patients.

Subscribe to Urology Times to get monthly news from the leading news source for urologists.