Real-World Treatment Patterns in Metastatic Castration-Resistant Prostate Cancer Across Europe (France, Germany, Italy, Spain, and the United Kingdom) and Japan

Patient characteristics, treatment patterns, and survival outcomes in patients with castration-resistant prostate cancer: results from the J-CaP registry

BACKGROUND

The optimal treatment sequence of approved therapies for castration-resistant prostate cancer (PC) is unclear. This study assessed real-world patient characteristics, treatment patterns, and effectiveness in patients with castration-resistant PC in Japan.

METHODS

Using data from the Japan Study Group of Prostate Cancer registry (2016-2018), this retrospective study included patients with ≥1 record of: primary androgen-deprivation therapy for hormone-sensitive PC and clinical progression to castration-resistant PC during primary androgen-deprivation therapy. The primary outcomes were patient characteristics, treatment patterns, and treatment duration. Other outcomes were overall survival (OS), cancer-specific survival (CSS), time to disease progression, and time to second disease progression.

RESULTS

A total of 600 patients were included. The mean age was 75.3 (SD: 7.9) years at PC diagnosis. The median prostate-specific antigen level was 135.5 (IQR: 37.3-542.2) ng/mL. The most common first-line castration-resistant PC treatments were enzalutamide (30%), docetaxel (20%), abiraterone (18%), flutamide (12%), and bicalutamide (8.7%). The most common second-line treatments were enzalutamide (28.5%), abiraterone (21.9%), and docetaxel (16.6%). The median treatment duration for enzalutamide, docetaxel, abiraterone, and flutamide was 254.0, 176.0, 197.0, and 111.5 days, respectively. Across all treatments, the median OS, CSS, time to disease progression, and second disease progression was 1028.0, 1239.0, 616.0, and 887.0 days, respectively.

CONCLUSION

Androgen receptor signaling inhibitors and docetaxel were the most common first- and second-line castration-resistant PC treatments. Enzalutamide was the preferred androgen receptor signaling inhibitor with the longest treatment duration.

A Large-scale Digital Survey of Patients with Localized and Advanced Prostate Cancer in Germany, the UK, and the USA

BACKGROUND AND OBJECTIVE

We conducted a prostate cancer (PC) survey to provide a better understanding of the patient journey, expectations, and attitudes related to treatment.

METHODS

This large-scale digital survey of patients with localized or advanced PC from Germany, the UK, and the USA assessed their demographics, diagnosis, treatment history, perception of therapy, medical care team involvement, and health-related quality of life (HRQoL). The survey was designed and interpreted by a large multistakeholder group. Descriptive statistics were primarily used. Univariate and multivariate analyses of the impact on HRQoL by demographic and clinical factors, including disease and treatment history, were examined using simple and multiple linear regression analyses, respectively.

KEY FINDINGS AND LIMITATIONS

Overall, 15 824 participants completed the survey and 14 812 reported their disease status (79.6% had localized and 20.4% had advanced PC). Across the three countries, there were similarities and differences in diagnosis, treatment patterns, and medical specialists involved. Diagnosis by routine screening was more common in Germany and the USA than in the UK. For localized disease, the most common treatment was prostatectomy in Germany and the USA, and radiotherapy in the UK. Hormone therapy was the most common treatment for advanced disease across countries. Overall, treatment satisfaction was high but decreased over time. Patients not on active treatment generally had negative perceptions of treatment types and their impact on HRQoL. Advanced disease and multiple comorbidities were identified as the predictors of worse HRQoL.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This study highlights differences in the PC patient journey in Germany, the UK, and the USA. HRQoL did not differ between countries but was affected by advanced disease status and comorbidity burden. A common approach to PC diagnosis, treatment practices, and guidelines could improve outcomes.

Real-world treatment patterns and genetic testing in a metastatic castration-resistant prostate cancer setting in Europe

AIM

This study described treatment patterns, reasons for treatment, and homologous recombination repair mutation (HRRm) testing patterns in a real-world metastatic castration-resistant prostate cancer (mCRPC) population in Europe.

METHODS

Data were drawn from the Adelphi Prostate Cancer Disease Specific Programme™, a cross-sectional survey of physicians and patients conducted in France, Germany, Italy, Spain, and the United Kingdom, November 2022-May 2023. Physicians provided clinical characteristics, treatment and HRRm testing patterns, and reasons for treatment for eight consecutive patients with mCRPC. Most analyses were descriptive; treatment reasons were compared using Fisher's Exact test.

RESULTS

Physicians provided data for 1,737 mCRPC patients. Most patients (73%) were androgen receptor pathway inhibitor (ARPi)-naïve at first-line (1 L) mCRPC. Here, at 1 L mCRPC, 60% of patients received ARPi and 24% chemotherapy. Of those who received ARPi prior to mCRPC (n = 291), 60% received chemotherapy at mCRPC and 21% ARPi. Overall, 37% were HRRm tested. Treatment patterns, sequencing, reasons, and HRRm testing varied by country, physician specialty, and practice setting.

CONCLUSIONS

Treatment patterns generally followed guidelines. ARPi prescriptions prior to mCRPC were numerically higher than previously reported, however HRRm testing rates were still low meaning mCRPC patients may miss out on more effective targeted treatments.

Real-world treatment patterns and survival outcomes in men with metastatic castration-resistant prostate cancer in Finland: a national, population-based cohort study

BACKGROUND

Metastatic castration-resistant prostate cancer (mCRPC) treatment is advancing yet Nordic, real-world evidence for its use is scarce. In this population-based cohort study, we describe characteristics of patients with mCRPC, and their treatment patterns and survival outcomes in Finland.

METHODS

Incident patients with mCRPC diagnosed during 2013-2021 were identified from data lakes in two large and representative, Finnish hospital districts, and linked to data on drug purchases and causes of death from national registries.

RESULTS

Of a total of 31,307 patients with prostate cancer, 2,475 progressed to mCRPC during 2013-2021. Those who received no life-prolonging treatment(s) (28% overall) were older with more comorbidities than treated patients. After 2018, the proportion of patients who received life-prolonging treatments increased from 61% to 80%. Of those who received treatment before androgen receptor pathway inhibitors (ARPIs) were reimbursed as first-line (1L) treatment for mCRPC in Finland, 68% received docetaxel, 19% abiraterone and 12% enzalutamide 1L; post-reimbursement, 4% received docetaxel, 24% abiraterone and 71% enzalutamide 1L. Median overall survival for treated patients with mCRPC was 28.3 (95% CI: 26.3-30.4) and 38.5 (95% CI: 32.7-42.1) months pre- and post-reimbursement of 1L-ARPIs, respectively.

INTERPRETATION

The ARPI reimbursement status changes significantly influenced treatment patterns for mCRPC in Finland, favouring enzalutamide over docetaxel. This expanded the pool of men eligible for 1L treatment and improved overall survival by a median of 10 months. These findings highlight the importance of health policy decisions in shaping treatment strategies and patient outcomes in prostate cancer.

Intensification Approaches and Treatment Sequencing in Metastatic Castration-resistant Prostate Cancer: A Systematic Review

BACKGROUND AND OBJECTIVE

Recently, research on treatment intensification has gathered momentum, and three novel therapy combinations were approved for metastatic castration-resistant prostate cancer (mCRPC). This systematic review summarizes the current and emerging evidence around intensified strategies for mCRPC and provides guidance for an ideal therapeutic sequencing.

METHODS

Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines were followed to perform this review. PubMed, EMBASE, Web of Science, Cochrane Library, ClinicalTrials.gov, and major international societies' online proceedings were searched comprehensively until May 15, 2024, for terms related to treatment intensification and sequencing for mCRPC.

KEY FINDINGS AND LIMITATIONS

Overall, 28 clinical trials and 24 ongoing studies of intensification treatments were included in this review. Algorithms of optimal sequencing of approved treatments for mCRPC were outlined according to the use of androgen receptor pathway inhibitors (ARPIs) with or without docetaxel for earlier disease states. In first line, poly(ADP-ribose) polymerase inhibitor + ARPI combinations improve radiographical progression-free survival (rPFS), particularly for those with BRCA1/2 alterations. The AKT inhibitor combination of ipatasertib + abiraterone extends rPFS in those with PTEN loss or PIK3CA/AKT1/PTEN alterations. In those with two or more risk factors for early progression on enzalutamide, radionuclide 177-Lu-PSMA-617 + enzalutamide prolongs progression-free survival. Ongoing research of intensified approaches for mCRPC, and available and potential predictive and prognostic biomarkers are discussed.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Recent approvals and ongoing investigations of single agents and intensification approaches will keep transforming the mCRPC treatment landscape. Improvement of patient profiling applying recognized genomic, molecular, and clinical predictive and prognostic indicators is fundamental to optimize sequential use of available therapies.

Androgen-ablative therapies inducing CXCL8 regulates mTORC1/SREBP2-dependent cholesterol biosynthesis to support progression of androgen receptor negative prostate cancer cells

Treatment with androgen-ablative therapies effectively inhibited androgen receptor (AR)-positive (AR+) prostate cancer (PCa) cell subtypes, but it resulted in an increase in AR-negative (AR-) PCa cell subtypes. The present study aimed to investigate the debated mechanisms responsible for the changing proportion of cell types, identifying CXCL8 as a synthetic essential effector of AR- PCa cells. AR- PCa cells were found to be susceptible to CXCL8 depletion or inhibition, which impaired their survival. Mechanistically, androgen-ablative therapies resulted in the suppression of AR signaling, leading to the upregulation of CXCL8 gene transcription. CXCL8, in turn, activated the mTORC1 pathway, which increased de novo cholesterol synthesis by activating sterol regulatory element-binding protein-2 (SREBP2). Together, these results suggested that the CXCL8-mTORC1-SREBP2 axis contributed to the exacerbation of tumorigenicity in AR- PCa cells under androgen-ablative therapies.

Treatment intensification with radium-223 plus enzalutamide in patients with metastatic castration-resistant prostate cancer

Several life-prolonging therapies with diverse mechanisms of action (MoA) are available for the treatment of metastatic hormone-sensitive/castration-resistant prostate cancer, with many patients requiring multiple lines of therapy. Nevertheless, treatment optimization to further delay disease progression and improve overall survival remains an unmet need. Despite the number of agents with differing MoAs approved for advanced prostate cancer, many patients receive only one or two life-prolonging therapies. One strategy for enhancing the benefit of treatment for this aggressive disease is combining therapies with different MoAs (treatment intensification) early in the disease course, which may be more effective than administering therapies sequentially, yet still allow for subsequent sequential use of individual therapies to optimize patient outcomes. In this narrative review we discuss the rationale for combining 223radium dichloride (223Ra; an alpha-emitting radionuclide) with enzalutamide (an androgen receptor inhibitor) for treatment intensification, including their differing MoAs, their individual efficacy in this setting, and their largely non-overlapping tolerability profiles. We also summarize the preclinical and clinical data available for this combination to date, including interim safety data from the phase 3 EORTC 1333/PEACE III study which highlight the low fracture risk of 223Ra plus enzalutamide when administered concomitantly with bone health agents. Relevant data were sourced from clinical studies published by the authors and via searches of PubMed, clinical trial registries and congress abstracts.

177Lu-PSMA-617 versus a change of androgen receptor pathway inhibitor therapy for taxane-naive patients with progressive metastatic castration-resistant prostate cancer (PSMAfore): a phase 3, randomised, controlled trial

BACKGROUND

[177Lu]Lu-PSMA-617 (177Lu-PSMA-617) prolongs radiographic progression-free survival and overall survival in patients with metastatic castration-resistant prostate cancer previously treated with androgen receptor pathway inhibitor (ARPI) and taxane therapy. We aimed to investigate the efficacy of 177Lu-PSMA-617 in patients with taxane-naive metastatic castration-resistant prostate cancer.

METHODS

In this phase 3, randomised, controlled trial conducted at 74 sites across Europe and North America, taxane-naive patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer who had progressed once on a previous ARPI were randomly allocated (1:1) to open-label, intravenous 177Lu-PSMA-617 at a dosage of 7·4 GBq (200 mCi) ± 10% once every 6 weeks for six cycles, or a change of ARPI (to abiraterone or enzalutamide, administered orally on a continuous basis per product labelling). Crossover from ARPI change to 177Lu-PSMA-617 was allowed after centrally confirmed radiographic progression. The primary endpoint was radiographic progression-free survival, defined as the time from randomisation until radiographic progression or death, assessed in the intention-to-treat population. Safety was a secondary endpoint. This study is registered with ClinicalTrials.gov (NCT04689828) and is ongoing. In this primary report of the study, we present primary (first data cutoff) and updated (third data cutoff) analyses of radiographic progression-free survival; all other data are based on the third data cutoff.

FINDINGS

Overall, of the 585 patients screened, 468 met all eligibility criteria and were randomly allocated between June 15, 2021 and Oct 7, 2022 to receive 177Lu-PSMA-617 (234 [50%] patients) or ARPI change (234 [50%]). Baseline characteristics were mostly similar between groups; median number of 177Lu-PSMA-617 cycles was 6·0 (IQR 4·0-6·0). Of patients assigned to ARPI change, 134 (57%) crossed over to receive 177Lu-PSMA-617. In the primary analysis (median time from randomisation to first data cutoff 7·26 months [IQR 3·38-10·55]), the median radiographic progression-free survival was 9·30 months (95% CI 6·77-not estimable) in the 177Lu-PSMA-617 group versus 5·55 months (4·04-5·95) in the ARPI change group (hazard ratio [HR] 0·41 [95% CI 0·29-0·56]; p<0·0001). In the updated analysis at time of the third data cutoff (median time from randomisation to third data cutoff 24·11 months [IQR 20·24-27·40]), median radiographic progression-free survival was 11·60 months (95% CI 9·30-14·19) in the 177Lu-PSMA-617 group versus 5·59 months (4·21-5·95) in the ARPI change group (HR 0·49 [95% CI 0·39-0·61]). The incidence of grade 3-5 adverse events was lower in the 177Lu-PSMA-617 group (at least one event in 81 [36%] of 227 patients; four [2%] grade 5 [none treatment related]) than the ARPI change group (112 [48%] of 232; five [2%] grade 5 [one treatment related]).

INTERPRETATION

177Lu-PSMA-617 prolonged radiographic progression-free survival relative to ARPI change, with a favourable safety profile. For patients with PSMA-positive metastatic castration-resistant prostate cancer who are being considered for a change of ARPI after progression on a previous ARPI, 177Lu-PSMA-617 may be an effective treatment alternative.

FUNDING

Novartis.

Strategic Advances in Combination Therapy for Metastatic Castration-Sensitive Prostate Cancer: Current Insights and Future Perspectives

The contemporary treatment for metastatic castration-sensitive prostate cancer (mCSPC) has evolved significantly, building on successes in managing metastatic castration-resistant prostate cancer (mCRPC). Although androgen deprivation therapy (ADT) alone has long been the cornerstone of mCSPC treatment, combination therapies have emerged as the new standard of care based on recent advances, offering improved survival outcomes. Landmark phase 3 trials demonstrated that adding chemotherapy (docetaxel) and androgen receptor pathway inhibitors to ADT significantly enhances overall survival, particularly for patients with high-volume, high-risk, or de novo metastatic disease. Despite these advancements, a concerning gap between evidence-based guidelines and real-world practice remains, with many patients not receiving recommended combination therapies. The challenge in optimizing therapy sequences, considering both disease control and treatment burdens, and identifying clinical and biological subgroups that could benefit from personalized treatment strategies persists. The advent of triplet therapy has shown promise in extending survival, but the uro-oncology community must narrow the gap between evidence and practice to deliver the most effective care. Current research is focused on refining treatment approaches and utilizing biomarkers to guide therapy selection, aiming to offer more personalized and adaptive strategies for mCSPC management. Thus, aligning clinical practices with the evolving evidence is urgently needed to improve outcomes for patients facing this incurable disease.

Evaluation of Second-Line Treatment for Castration-Resistant Prostate Cancer following the Administration of Upfront Androgen Receptor Signaling Inhibitors

This study evaluated the effects of docetaxel and androgen receptor signaling inhibitors as second-line treatments in patients with castration-resistant prostate cancer after androgen receptor signaling inhibitors as first-line treatment. This study retrospectively evaluated the clinical outcomes of second-line treatment with docetaxel or androgen receptor signaling inhibitor in patients with castration-resistant prostate cancer who received first-line treatment with androgen receptor signaling inhibitors. Clinical backgrounds and outcomes were compared between docetaxel and androgen receptor signaling inhibitors as second-line treatment. Of 59 patients, 21 (35.6%) and 38 (64.4%) received docetaxel and androgen receptor signaling inhibitors as second-line treatment after first-line treatment with androgen receptor signaling inhibitors, respectively. In the second-line setting, the median progression-free survival was longer with androgen receptor signaling inhibitor than with docetaxel (17 versus 6 months, P=0.014). In the first-line setting, the median progression-free survival was longer with androgen receptor signaling inhibitors than with docetaxel (32 versus 25 months, P=0.014); however, no significant difference was found in the overall survival. Multivariate analysis revealed that there was no significant association between second-line treatment and survival, and first-line treatment with abiraterone was identified as a prognostic factor for progression-free survival. Subgroup analysis showed that the abiraterone-enzalutamide sequence was more effective than the other three sequences for progression-free survival and overall survival. This study suggests that second-line treatment with an androgen receptor signaling inhibitor for castration-resistant prostate cancer after androgen receptor signaling inhibitors as first-line treatment may be more beneficial, particularly with abiraterone as the upfront treatment.

Quality of Life Evaluation in Patients with Follicular Cell Lymphoma: A Real-World Study in Europe and the United States

INTRODUCTION

Follicular lymphoma (FL) is an indolent subtype of non-Hodgkin's lymphoma (NHL), characterized by a long natural course of remissions/relapses. We aimed to evaluate real-world quality of life (QoL) in patients with FL, by line of therapy (LOT), and across countries.

METHODS

Data were drawn from the Adelphi FL Disease Specific Programme™, a cross-sectional survey of physicians and their patients in Europe [France, Germany, Italy, Spain, the United Kingdom (UK)], and the United States (US) from June 2021 to January 2022. Patients provided demographics and patient-reported outcomes via the European Organisation for Research and Treatment of Cancer QoL questionnaire (EORTC QLQ-C30). Bivariate analysis assessed QoL versus NHL, across LOT [first line (1L), second line (2L), third line or later (3L+)] and country.

RESULTS

Patients (n = 401) had a mean [standard deviation (SD)] age of 66.0 (9.24) years, 58.1% were male, and 41.9%/22.9% were Ann Arbor stage III/IV. Patients with FL mean EORTC global health status (GHS)/QoL, nausea/vomiting, pain, dyspnea, appetite loss, and diarrhea scores were statistically significantly worse (p < 0.05) versus the NHL reference values. Mean (SD) GHS/QoL worsened from 1L [56.5 (22.21)] to 3L+ [50.4 (20.11)]. Physical and role functioning, fatigue, pain, dyspnea, and diarrhea scores also significantly worsened across later LOTs (p < 0.05). Across all functional domains, mean scores were significantly lower (p < 0.05) and almost all symptom scores (excluding diarrhea) were significantly higher (p < 0.05) for European versus US patients.

CONCLUSIONS

Patients with FL at later LOTs had significantly worse scores in most QoL aspects than earlier LOTs. European patients had significantly lower functioning and higher symptom burden than in the US. These real-world findings highlight the need for novel FL therapies that alleviate patient burden, positively impacting QoL.

A global phase II randomized trial comparing oral taxane ModraDoc006/r to intravenous docetaxel in metastatic castration resistant prostate cancer

STUDY AIM

ModraDoc006, an oral formulation of docetaxel, is co-administered with the cytochrome P450-3A4 and P-glycoprotein inhibitor, ritonavir (r): ModraDoc006/r. The preliminary efficacy and safety of oral ModraDoc006/r was evaluated in a global randomized phase II trial and compared to the current standard chemotherapy regimen of intravenous (i.v.) docetaxel and prednisone.

METHODS

103 mCRPC patients, chemotherapy-naïve with/without abiraterone and/or enzalutamide pretreated, with adequate organ function and evaluable disease per RECIST v1.1 and PCWG3 guidelines were randomized 1:1 into two cohorts. In Cohort 1, 49 patients received docetaxel 75 mg/m2 i.v. every 3 weeks (Q3W). In Cohort 2, 52 patients received ModraDoc006/r; 21 patients with a starting dose of ModraDoc006 30 mg with ritonavir 200 mg in the morning and ModraDoc006 20 mg with ritonavir 100 mg in the evening (30-20/200-100 mg) bi-daily-once-weekly (BIDW) on Days 1, 8, and 15 of a 21-day cycle. To alleviate tolerability, the starting dose was amended to ModraDoc006/r 20-20/200-100 mg in another 31 patients. All patients received prednisone 10 mg daily. Primary endpoint was rPFS.

RESULTS

There was no significant difference in rPFS between the 2 arms (p = 0.1465). Median rPFS was 9.5 months and 11.1 months (95% CI) for ModraDoc006/r and i.v. docetaxel, respectively. Partial response was noted in 44.1% and 38.7% measurable disease patients, and 50% decline of PSA was seen in 23 (50%) and 26 (56.5%) evaluable cases treated with ModraDoc006/r and i.v. docetaxel, respectively. The safety profile of ModraDoc006/r 20-20/200-100 mg dose was significantly better than i.v. docetaxel, with mild (mostly Grade 1) gastrointestinal toxicities, no hematologic adverse events, and neuropathy and alopecia incidence of 11.5% and 25%, respectively.

CONCLUSIONS

ModraDoc006/r potentially represents a widely applicable, convenient, effective, and better tolerated oral taxane therapy option for mCRPC. Further investigation of ModraDoc006/r in a large randomized trial is warranted.

Second-line treatment options in metastatic castration-resistant prostate cancer after progression on first-line androgen-receptor targeting therapies: A systematic review and Bayesian network analysis

OBJECTIVE

To summarize and indirectly compare the efficacy and safety of different second-line systematic therapies after first-line androgen-receptor targeting therapies (ARTs) for biomarker-unselected metastatic castration-resistant prostate cancer (mCRPC) patients.

METHODS

Studies published in English up to May 2023 were identified in PubMed, Web of Science and ASCO-GU 2023. Studies accessing the efficacy and safety of second-line systematic therapies after first-line ARTs for biomarker-unselected mCRPC patients were eligible for current systematic review and network meta-analysis (NMA).

RESULTS

Thirty-two studies with 5388 patients and 10 unique treatment modalities met our inclusion criteria. Current evidence suggested that docetaxel (DOC) combined with the same ART as first-line (ART1) (ART1 + DOC) were associated with significantly improved PSA response, PSA progression-free survival (PFS) and clinical or radiographic PFS (rPFS) compared with other reported second-line systematic therapies, including DOC. An increase in toxicity was observed with ART1 + DOC. Our NMA indicated that DOC monotherapy was only inferior to ART1 + DOC in improvement disease outcomes. The incidence of toxicity between patients received second-line DOC and an alternative ART (ART2) was similar.

CONCLUSION

The available evidence reviewed in our work suggested a clinical benefit of DOC nomotherapy and DOC plus ART1 as the second-line systematic therapy for biomarker-unselected mCRPC patients progressed on a first-line ART. More studies and RCTs are needed to evaluate the optimal second-line treatments for mCRPC patients with one prior first-line ART.

Management of patients with localized prostate cancer and biochemical recurrence in Spain: A medical survey

INTRODUCTION

The management of patients with prostate cancer (PCa) is established in clinical practice guidelines, which are based on randomized studies according to the level of evidence. In Spain, the degree of compliance with these guidelines in clinical practice is unknown.

OBJECTIVES

To describe the profiles of PCa patients at the time of diagnosis and the management of patients with localized PCa and those with BCR in Spain.

MATERIALS & METHODS

A medical survey was conducted in specialized care (85 urologists [UROs], 64 radiation oncologists [ROs], and 21 medical oncologists [MOs]). Three questionnaires were developed for this study with 22 (UROs and ROs) or 21 questions (MOs).

RESULTS

The annual incidence of PCa was 24,057 in participating hospitals (N = 131). The extrapolated annual incidence in Spain is 40,531 cases. The estimated prevalence of PCa in Spain is 221,689. Of note, 79% and 80% of patients seen by UROs and ROs, respectively had localized PCa at diagnosis. Biopsy was the most used diagnostic test among the three specialties, followed by abdominopelvic computer tomography. More than 90% of patients with BCR underwent standard tests. Next generation imaging tests and PET-choline/PSMA are still used residually. Most patients with localized PCa are currently treated with either surgery or radiotherapy, while for BCR patients, UROs and ROs prefer radiotherapy and MOs androgen deprivation therapy alone or in combination.

CONCLUSION

This study describes patient profiles at the time of diagnosis and provides an overview of the current therapeutic management of localized PCa and BCR in clinical practice in Spain.

Treatment Patterns and Clinical Outcomes Among Patients With Metastatic Prostate Cancer Harboring Homologous Recombination Repair Mutations

BACKGROUND

There is currently limited literature assessing the real-world treatment patterns and clinical outcomes of patients with metastatic castration-resistant prostate cancer (mCRPC) and homologous recombination repair (HRR) mutations.

METHODS

Medical charts were abstracted for mCRPC patients with ≥ 1 of 12 HRR somatic gene alterations treated at US oncology centers participating in the American Association for Cancer Research Project Genomics Evidence Neoplasia Information Exchange. Treatment patterns and clinical outcomes were assessed from the initiation of first-line or later (1L+) mCRPC therapy received on or after July 1, 2014.

RESULTS

Among 138 patients included in the study, the most common somatic HRR mutations were CDK12 (47.8%), BRCA2 (22.5%), and ATM (21.0%). Novel hormonal therapy and taxane chemotherapy were most commonly used in 1L; taxane use increased in later lines. Median overall survival (95% confidence interval [CI]) was 36.3 (30.7-47.8) months from initiation of 1L therapy and decreased for subsequent lines. Similarly, there was a trend of decreasing progression-free survival and prostate-specific antigen response from 1L to 4L+ therapy.

CONCLUSIONS

Treatment patterns identified in this study were similar to those among patients with mCRPC regardless of tumor HRR mutation status in the literature.

Cancer Care by Committee to be Superseded by Personal Physician-Patient Partnership Informed by Artificial Intelligence

Multidisciplinary tumor boards (MTBs) have become the reference standard of cancer management, founded upon randomized controlled trial (RCT) evidence-based guidelines. The inordinate delays inherent in awaiting formal regulatory agency approvals of novel therapeutic agents, and the rigidities and nongeneralizability of this regimented approach, often deny cancer patients timely access to effective innovative treatment. Reluctance of MTBs to accept theranostic care of patients with advanced neuroendocrine tumors (NETs) and metastatic castrate-resistant prostate cancer resulted in decades of delay in the incorporation of 177Lu-octreotate and 177Lu-prostate-specific membrane antigen (PSMA) into routine clinical oncology practice. Recent developments in immunotherapy and molecular targeted precision therapy, based on N-of-One individual multifactorial genome analyses, have greatly increased the complexity of decision-making. Burgeoning specialist workload and tight time frames now threaten to overwhelm the logistically, and emotionally, demanding MTB system. It is hypothesized that the advent of advanced artificial intelligence technology and Chatbot natural language algorithms will shift the cancer care paradigm from a MTB management model toward a personal physician-patient shared-care partnership for real-world practice of precision individualized holistic oncology.

Treatment landscape and burden of disease in metastatic castration-resistant prostate cancer: systematic and structured literature reviews

Purpose

Metastatic castration-resistant prostate cancer (mCRPC) is a lethal disease that imposes a major burden on patients and healthcare systems. Three structured literature reviews (treatment guidelines, treatment landscape, and human/clinical/patient burden) and one systematic literature review (economic burden) were conducted to better understand the disease burden and unmet needs for patients with late-stage mCRPC, for whom optimal treatment options are unclear.

Methods

Embase®, MEDLINE®, MEDLINE® In-Process, the CENTRAL database (structured and systematic reviews), and the Centre for Reviews and Dissemination database (systematic review only) were searched for English-language records from 2009 to 2021 to identify mCRPC treatment guidelines and studies related to the treatment landscape and the humanistic/economic burden of mCRPC in adult men (aged ≥18 years) of any ethnicity.

Results

In total, six records were included for the treatment patterns review, 14 records for humanistic burden, nine records for economic burden, three records (two studies) for efficacy, and eight records for safety. Real-world treatment patterns were broadly aligned with treatment guidelines and provided no optimal treatment sequencing beyond second line other than palliative care. Current post-docetaxel treatments in mCRPC are associated with adverse events that cause relatively high rates of treatment discontinuation or disruption. The humanistic and economic burdens associated with mCRPC are high.

Conclusion

The findings highlight a lack of treatment options with novel mechanisms of action and more tolerable safety profiles that satisfy a risk-to-benefit ratio aligned with patient needs and preferences for patients with late-stage mCRPC. Treatment approaches that improve survival and health-related quality of life are needed, ideally while simultaneously reducing costs and healthcare resource utilization.

HTA and Reimbursement Status of Metastatic Hormone‑Sensitive Prostate Cancer, Non-Metastatic Castration-Resistant Prostate Cancer, and Metastatic Castration-Resistant Prostate Cancer Treatments in Europe: A Patient Access Landscape Review

Background: Prostate cancer is the second most common cancer in men, with up to one-third of men being diagnosed in their lifetime. Recently, novel therapies have received regulatory approval with significant improvement in overall survival for metastatic castration-resistant prostate cancer, metastatic hormone-sensitive prostate cancer, and nonmetastatic castration-resistant prostate cancer. To improve decision-making regarding the value of anticancer therapies and support standardized assessment for use by health technology assessment (HTA) agencies, the European Society for Medical Oncology (ESMO) has developed a Magnitude of Clinical Benefit Scale (MCBS). Objective: This review aimed to map HTA status, reimbursement restrictions, and patient access for 3 advanced prostate cancer indications across 23 European countries during 2011-2021. Methods: HTA, country reimbursement lists, and ESMO-MCBS scorecards were reviewed for evidence and data across 26 European countries. Results: The analysis demonstrated that only in Greece, Germany, and Sweden was there full access across all included prostate cancer treatments. Treatments available for metastatic castration-resistant prostate cancer were widely reimbursed, with both abiraterone and enzalutamide accessible in all countries. In 3 countries (Hungary, the Netherlands, and Switzerland), there was a statistically significant difference (P<.05) between status of reimbursement and ESMO-MCBS "substantial benefit" (score of 4 or 5) vs "no substantial benefit" (score <4). Conclusion: Overall, the impact of the ESMO-MCBS on reimbursement decisions in Europe is unclear, with significant variation across the countries included in this review.

Triplet Therapy in Metastatic Castrate Sensitive Prostate Cancer (mCSPC)-A Potential New Standard of Care

The treatment paradigm for metastatic castrate-sensitive prostate cancer (mCSPC) has evolved rapidly in the past decade with the approval of several life-prolonging therapies including docetaxel chemotherapy and multiple androgen receptor pathway inhibitors (ARPI) in combination with androgen deprivation therapy (ADT). Recently reported phase-three trials have demonstrated a survival benefit of upfront triplet therapy with ADT, docetaxel plus either abiraterone acetate or darolutamide when compared to ADT plus docetaxel alone. However, multiple questions including the incremental benefit of docetaxel to a combination of ADT and ARPI, the timing of ARPI, optimal patient selection for triplet therapy and clinical and genomic biomarkers still remain to be answered. Moreover, real-world data suggest suboptimal treatment intensification with many patients treated with ADT alone highlighting challenges in implementation. In this article, we review the phase-three data associated with triplet therapy in mCSPC. We also discuss the knowledge gaps that exist despite the completion of these studies and how ongoing studies are likely to change the paradigm in the near future. Finally, we provide a simple algorithm based on current data that clinicians can use in daily practice to select patients for appropriate treatment strategies.

Development of castration resistance in prostate cancer patients treated with luteinizing hormone-releasing hormone analogues (LHRHa): results of the ANARESISTANCE study

PURPOSE

Evaluate the percentage of patients with prostate cancer treated with luteinizing hormone-releasing hormone analogues (LHRHa) that develop castration resistance after a follow-up period of 3 years. The secondary objective is to evaluate the variables potentially related to the progression to castration resistant prostate cancer (CRPC).

METHODS

A post-authorization, nation-wide, multicenter, prospective, observational, and longitudinal study that included 416 patients treated with LHRHa between 2012 and 2017 is presented. Patients were followed for 3 years or until development of CRPC, thus completing a per-protocol population of 350 patients. A Cox regression analysis was carried out to evaluate factors involved in progression to CRPC.

RESULTS

After 3 years of treatment with LHRHa 18.2% of patients developed CRPC. In contrast, in the subgroup analysis, 39.6% of the metastatic patients developed CRPC, compared with 8.8% of the non-metastatic patients. The patients with the highest risk of developing CRPC were those with a nadir prostate-specific antigen (PSA) > 2 ng/ml (HR 21.6; 95% CI 11.7-39.8; p < 0.001) and those receiving concomitant medication, most commonly bicalutamide (HR 1.8; 95% CI 1-3.1, p = 0.0431).

CONCLUSIONS

The proportion of metastatic patients developing CRPC after 3 years of treatment with LHRHa is consistent with what has been previously described in the literature. In addition, this study provides new findings on CRPC in non-metastatic patients. Concomitant medication and nadir PSA are statistically significant predictive factors for the time to diagnosis of CRPC, the nadir PSA being the strongest predictor.

Factors influencing survival in metastatic castration resistant prostate cancer therapy

INTRODUCTION

The number of patients with metastatic castration resistant prostate cancer (mCRPC) is expecting to increase due to the long-life expectancy of those with advanced disease who are also more commonly diagnosed today because of stage migration. Several compounds are available for treating these patients.

AREAS COVERED

We reviewed currently available treatments for mCRPC, their mechanism of action and resistance and we explored possible predictors of treatment success useful to predict survival in mCRPC patients.

EXPERT OPINION

A combination of molecular, clinical, pathological, and imaging features is necessary to correctly estimate patients' risk of death. The combination of these biomarkers may allow clinicians to tailor treatments based on cancer history and patients' features. The search of predictive biomarkers remains an unmet medical need for most patients with mCRPC.