Urologists positive about abiraterone integration

More than 96% of urologists surveyed said that incorporating abiraterone acetate (ZYTIGA) treatment into practice for patients with metastatic castrate-resistant prostate cancer is easy or manageable after overcoming initial barriers, according to new research presented at the Genitourinary Cancers Symposium in Orlando, FL.

Lead author Andrew Feifer, MD, staff uro-oncologist at Trillium Health Partners and associate staff at University Health Network, Toronto, told Urology Times that he and his co-authors set out to better understand whether urologists’ real-world interpretations of incorporating abiraterone acetate into practice mimicked the positive data coming out of two phase III trials on the drug’s use in metastatic castration-resistant prostate cancer.

Abiraterone has been shown to increase overall survival and improve quality of life. In one phase III study, patients with metastatic castration-resistant prostate cancer who were treated with abiraterone and prednisone had a mean 8.2-month longer overall survival compared to patients who received prednisone only (N Engl J Med 2013; 368:138-48). The abiraterone-prednisone group also had a longer time to initiation of cytotoxic chemotherapy, lower opiate use for cancer-related pain, improved PSA progression, and less decline in performance status, according to the study.

In the current study, the authors developed a questionnaire to assess academic and community urologists’ experiences with integrating the oral antiandrogen therapy into practice. Their study reflects responses from 30 sites in Canada, of which 93.3% of providers responding were urologists. Sixty-three percent of the urologists responding were in the community setting, versus 30% in academic practice.

“What we found was that roughly 50% of urologists involved were very comfortable with administering the medication to their patients,” Dr. Feifer said. “[Another] 46.7% had really no significant concerns, and 3.3% thought there were really tremendous barriers to implementation.”

Next: Barriers included inadequate resources

Barriers included inadequate resources

The 46.7% who had no significant concerns thought implementation was relatively simple once they overcame drug-related barriers, including devoting time to more follow-ups, having inadequate resources, and not having an appropriate infrastructure for implementation.

Read: Prostate Ca test influences decision-making post RP

“Some providers found there were certain barriers to integrating the drug properly-things like following up with labs and making sure that critical results for labs were seen on a very timely manner,” he said. “It’s not in the abstract, but some of the ancillary data we have is such that every practice from every community that we see is a little different. So, the needs of the provider to make sure they develop a good, safe practice for the administration of abiraterone are a little bit different. There has to be novel thinking and very deliberate attempts to evaluate and investigate what details of our practices need to be changed or modified to accommodate abiraterone patients.”

Still, nine in 10 respondents indicated they would continue to treat metastatic castration-resistant prostate cancer patients with abiraterone post-trial.

“The worst thing that could happen is the urologist doesn’t treat and doesn’t refer,” Dr. Feifer said.

While urologists have been intrinsically involved in the administration of antiandrogen therapy for treatment of most prostate cancer stages, treatment of metastatic castration-resistant prostate cancer patients fell largely within the medical oncologist’s domain until recent years.

“We have a keen awareness of how to manipulate testosterone, and we monitor testosterone all the time,” Dr. Feifer said.

Therapies for castration-resistant prostate cancer, however, were relegated to the medical oncologists because urologists had no oral therapies and no therapy that could be delivered in urologists’ offices that were any good, according to Dr. Feifer.

“They were toxic and not very efficacious. Those patients went to medical oncologists at tertiary care centers for the administration of cytotoxic chemotherapy,” he said.

In the last 5 years or so, abiraterone and enzalutamide (XTANDI), an oral androgen receptor blocker, surfaced in phase III studies as resulting in improved survival in men with metastatic castration-resistant prostate cancer, before and after chemotherapy.

Also see: RRP plus castration linked to improved survival

These two molecules target an area of which urologists are familiar, according to Dr. Feifer: the androgen receptor axis.

Next: Urologists must know potential side effects

Urologists must know potential side effects

Urologists who integrate abiraterone into practice need to have a keen understanding of the drug’s mechanism of action and potential side effects.

“These are not sort of ‘set-it-and-forget-it’ kind of drugs,” Dr. Feifer said.

Abiraterone patients need monitoring and follow-up-often more than other patients in a urologist’s office, according to Dr. Feifer. Monitoring includes checking blood pressure, measuring liver function, and checking for weight gain. It also requires looking at oral dentition to make sure there’s no risk of osteonecrosis of the jaw.

“Urologists also have to be aware of not sending the patients too late to the medical oncologist for further cytotoxic therapy,” he said. “The role of multidisciplinary care has to be enforced and really looked upon as an important tenet of care, because although urologists may be treating their patients with abiraterone acetate in their offices with safety and efficacy, waiting too long to broaden the scope of care to include an oncologist or radiation oncologist, where appropriate, is not in the best interest of the patient.”

Read: Online information linked to PCa treatment regret

The bottom line, according to Dr. Feifer, is that urologists within the community setting can very well increase their use of medications for metastatic castration-resistant prostate cancer, with safety and efficacy.

“Patients with whom they maintain long-term relationships can still be their patients when they have reached the castrate-resistant stage, and the subsequent treatment of these patients is… entirely possible and doable,” he said.

Dr. Feifer is a Janssen advisory board member and has received honoraria and travel, accomodations, and expenses from Janssen and Astellas Pharma. Several of his co-authors are consultants/advisers and/or employees of Janssen and/or have received honoraria from the company. Several co-authors have a financial or other relationship with other pharmaceutical companies. The current study was sponsored by Janssen.

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