Updated treatment recommendations for prostate cancer from the ESMO Clinical Practice Guideline considering treatment intensification and use of novel systemic agents

Learning From Evidence: Changes in Real-World Use of Second Androgen Receptor Targeted Treatments in Metastatic Castration-Resistant Prostate Cancer (mCRPC)

BACKGROUND

Androgen receptor targeted therapies (ART) play a major role in the treatment of metastatic castration-resistant prostate cancer (mCRPC). In recent years consensus has been reached that treatment with a second ART should be avoided due to low response rates. The aim of this study was to investigate if new scientific insights led to changes in clinical daily practice in the Netherlands.

METHODS

Patients included in the Dutch CAPRI-3 prostate cancer registry, currently encompassing 19 hospitals, and treated with at least 1 ART (ie, abiraterone or enzalutamide) were included. Patients were stratified based on start date of first ART (ART1) according to standard of care between 2016-2017, 2018-2019 and 2020-2021. Second ART (ART2) was defined as either direct (ART1>ART2) or at any given time (any ART2).

RESULTS

Between the first and last ART1 group, the prevalence of ART1>ART2 declined from 14.3% to 6.5% (P = .001) and the prevalence of any ART2 from 27.6% to 10.7% (P < .001). The decline was observed before recommendations were included in European guidelines. The use of other life-prolonging drugs (LPDs) after ART1 (ART1>LPD) increased. Patients who were selected for ART1>ART2 instead of ART1>LPD were older, less frequently treated with taxane-based chemotherapy for mHSPC and had a longer time to development of mCRPC.

CONCLUSIONS

New scientific insights were incorporated into clinical daily practice, with a significant decline in in the prevalence of sequential ART treatment, even before recommendations were included in European guidelines.

Initial management approach for localized/locally advanced disease is critical to guide metastatic castration-resistant prostate cancer care

BACKGROUND

Currently, several therapies are available for metastatic castration-resistant prostate cancer (mCRPC) but no specific clinical factors to personalize treatment. We first sought the prognostic value of duration on androgen-deprivation therapy (ADT) for hormone-sensitive prostate cancer (HSPC) in patients receiving androgen-receptor-signaling inhibitors (ARSI) for mCRPC.

METHODS

A multicenter cohort of mCRPC patients who started ARSI between July 2011 and October 2021 was identified. Based on their initial disease burden and duration on ADT for HSPC, primary progressive (PP) men were classified into four groups: low/intermediate-risk localized disease (LOC) and high-risk localized/locally advanced disease (LAD) and short-term (ST) < 24 vs. long-term (LT) ADT ≥ 24 months, whereas de novo (DN) mHSPC were subdivided into short-time vs. long-time to CRPC.

RESULTS

We included 919 mCRPC patients with a median age of 77 years [interquartile range (IQR) = 71-82)]. Median ADT duration in HSPC was 24 months (IQR = 14-40). Median follow-up was 91 months (IQR = 62-138), median OS and PFS from ARSI start were 20 (IQR 10-32) and 10 months (IQR = 5-19), respectively. In PP developing metastatic disease (n = 655, 71.3%), LOC and LAD with ST ADT had a greater than almost double-risk of death compared to LT ADT (LOC/ST: hazard ratio [HR] = 2.01; 95% CI 1.54-2.64; LAD/ST: HR = 1.73; 95% CI 1.34-2.24; p < 0.001). In the multivariate analysis including age, prognostic cohort, Gleason, ECOG, radical radiotherapy and prostatectomy, groups with ST ADT were associated with worse OS compared to LT ADT (LOC/ST: HR = 1.84; 95% CI 1.38-2.45; p < 0.001; LAD/ST: HR = 1.59; 95% CI 1.21-2.10; p < 0.001), along with ECOG > 2 (HR = 1.55; 95% CI 1.06-2.26; p = 0.03). There were also similar results of PFS. Moreover, long-time to CRPC in patients with history of DN mHSPC (n = 264, 28.7%) resulted in a better OS/PFS (HR = 0.76, 95% CI 0.56-1.02, p = 0.064 and HR = 0.74, 95% CI 0.55-0.99, p = 0.042, respectively).

CONCLUSIONS

Our study showed that duration on ADT for mHSPC was significantly associated with survival in mCRPC undergoing ARSI. These findings suggest a possible connection between initial management of prostate tumour and a better prognostication in mCRPC. Prospective trials are warranted.

Healthcare resource utilization and associated costs in patients with metastatic castration-resistant prostate cancer in Greece

BACKGROUND

Prostate cancer is a leading cause of cancer death among men. Metastatic castration-resistant prostate cancer (mCRPC) treatment has changed dramatically since the introduction of novel hormonal agents (NHAs); however, real-world data including healthcare resource utilization (HCRU) and costs are lacking in Greece.

METHODS

A subset of patients with HCRU data from the PROSPECT retrospective chart review study of patients with mCRPC who initiated first line (1 L) systemic therapy with chemotherapy or NHAs were included; HCRU and costs incurred during mCRPC treatment were estimated.

RESULTS

HCRU remained mostly stable across lines for the 119 patients included. Overall, median HCRU cost was €2,363.8 per patient per month (PPPM); 1 L was €2,475.0, second line (2 L) was €1,698.9, third line (3 L) was €2,499.0. Cost was mostly made up of systemic treatment (~90%). Overall HCRU 2 L costs were €688,795.1, contributing the least to the total HCRU cost of the three lines studied (€3,820,561.1). 2 L cost was lower as a greater proportion of patients received chemotherapy than in 1 L or 3 L, and chemotherapy was cheaper than NHAs.

CONCLUSIONS

Cost was impacted by type of systemic treatment; 2 L treatment costs were lower as a higher proportion of patients were treated with chemotherapy rather than NHAs.

Ketogenesis instigates immune suppression in enzalutamide resistant prostate cancer via OTUD7B β-hydroxybutyrylation

Next-generation androgen receptor inhibitors are the primary treatment for metastatic prostate cancer. Unfortunately, the majority of patients rapidly develop resistance. Resistance to enzalutamide has been linked to the emergence of an immunosuppressive tumor, although the underlying mechanisms remain poorly understood. In this study, we observed a marked overexpression of enzymes involved in the ketogenic pathway in enzalutamide-induced castration-resistant prostate cancer, which contributed to immune desertification and resistance to immunotherapy. Mechanistically, upregulation of the ketogenic pathway led to the accumulation of β-hydroxybutyrate, which promoted β-hydroxybutyrylation of the cell cycle-regulated deubiquitinase OTUD7B at lysine 511. This modification impaired the degradation of APC/C substrates, resulting in a subsequent reduction in cytoplasmic double-stranded DNA accumulation, thereby attenuating cGAS-STING activation and interferon expression. These findings shed light on the metabolic adaptations and immune escape driven by androgen receptor signaling inhibitors, potentially informing the development of more effective and durable therapeutic approaches in the near future.

Pembrolizumab plus enzalutamide versus placebo plus enzalutamide for chemotherapy-naive metastatic castration-resistant prostate cancer: the randomized, double-blind, phase III KEYNOTE-641 study

BACKGROUND

Established first- and second-line standard-of-care treatment options (abiraterone, enzalutamide, taxane chemotherapy) are available for patients with metastatic castration-resistant prostate cancer (mCRPC), but almost all patients experience subsequent disease progression. The randomized, double-blind, phase III KEYNOTE-641 study evaluated pembrolizumab plus enzalutamide versus placebo plus enzalutamide in participants with chemotherapy-naive mCRPC.

PATIENTS AND METHODS

Eligible participants were males aged ≥18 years with confirmed mCRPC and no prior chemotherapy except docetaxel in the hormone-sensitive setting. Prior abiraterone treatment was permitted. Participants were randomly assigned 1:1 to receive pembrolizumab 200 mg or placebo intravenously once every 3 weeks for ≤35 cycles plus enzalutamide 160 mg orally daily. Dual primary end points were overall survival (OS) and radiographic progression-free survival (rPFS) per PCWG-modified RECIST v1.1 by blinded independent central review. Safety was a secondary end point.

RESULTS

Between August 21, 2019, and June 10, 2022, 1244 participants were randomly assigned to pembrolizumab plus enzalutamide (n=621) or placebo plus enzalutamide (n=623). At the data cutoff date (December 12, 2022), median follow-up was 27.6 months (range, 6.1-39.8 months). Primary end points of OS (median, 24.7 vs 27.3 months; hazard ratio [HR], 1.04 [95% CI, 0.88-1.22]; P=0.66) and rPFS (median, 10.4 vs 9.0 months; HR, 0.98 [0.84-1.14]; P=0.41) with pembrolizumab plus enzalutamide versus placebo plus enzalutamide were not met. The prespecified boundary for futility for OS was crossed, and the study was stopped. Grade ≥3 treatment-related adverse events occurred in 192 of 615 participants (31.2%) with ≥1 dose of pembrolizumab plus enzalutamide and in 67 of 620 participants (10.8%) with ≥1 dose of placebo plus enzalutamide. Seventy-one (11.5%) and 21 (3.4%) participants, respectively, discontinued study treatment due to treatment-related adverse events.

CONCLUSION

Adding pembrolizumab to enzalutamide did not improve efficacy outcomes for participants with chemotherapy-naive mCRPC. Additional toxicity was observed with the combination regimen.

Pembrolizumab plus enzalutamide and androgen deprivation therapy versus placebo plus enzalutamide and androgen deprivation therapy for metastatic hormone-sensitive prostate cancer: the randomized, double-blind, phase III KEYNOTE-991 study

BACKGROUND

Despite treatment advances, most patients with metastatic hormone-sensitive prostate cancer (mHSPC) experience disease progression to castration-resistant disease within 5 years. The placebo-controlled, double-blind, phase III KEYNOTE-991 study evaluated the efficacy and safety of adding pembrolizumab to enzalutamide and androgen deprivation therapy (ADT) in participants with mHSPC.

PATIENTS AND METHODS

Eligible participants were aged ≥18 years with next-generation hormonal agent‒naive mHSPC. Participants were randomly assigned (1:1) to receive intravenous pembrolizumab 200 mg or placebo every 3 weeks for ≤35 cycles, with oral enzalutamide 160 mg and continuous ADT. Primary end points were radiographic progression-free survival (rPFS) and overall survival. Safety was a secondary end point.

RESULTS

Between March 2, 2020, and August 9, 2021, 626 participants were randomly assigned to pembrolizumab plus enzalutamide and ADT and 625 participants to placebo plus enzalutamide and ADT. At the first interim analysis, the median follow-up was 21.1 months (range, 14.8-32.0 months). rPFS was not superior with pembrolizumab versus placebo (median not reached in both arms; hazard ratio, 1.20 [95% confidence interval (CI), 0.96 to 1.49]; P = 0.9467). Median overall survival was not reached in either arm (hazard ratio, 1.16 [95% CI, 0.88 to 1.53]; not formally statistically tested per the multiplicity strategy). Grade ≥3 adverse events (AEs) and serious AEs were reported in 61.9% versus 38.1% and 40.3% versus 23.2% of participants in the pembrolizumab versus the placebo arm, respectively. Any-grade rash occurred at a higher frequency with pembrolizumab (25.1%) versus placebo (9.3%).

CONCLUSION

KEYNOTE-991 did not meet its primary end point and was stopped for futility. The addition of pembrolizumab to enzalutamide and ADT was associated with higher frequencies of grade ≥3 AEs and serious AEs than with placebo. Rash was identified as an additional safety signal with pembrolizumab plus enzalutamide and ADT.

Patient-reported Outcomes in KEYNOTE-921: Pembrolizumab with Docetaxel and Prednisone for Patients with Metastatic Castration-resistant Prostate Cancer

BACKGROUND AND OBJECTIVE

In the phase 3 KEYNOTE-921 study, the combination of pembrolizumab with docetaxel did not improve efficacy outcomes significantly in patients with chemotherapy-naive metastatic castration-resistant prostate cancer (mCRPC) after next-generation hormonal agents (NHAs). This analysis of KEYNOTE-921 assessed patient-reported outcomes (PROs) associated with pembrolizumab plus chemotherapy versus chemotherapy alone.

METHODS

Eligible patients were assigned randomly in a 1:1 ratio to receive pembrolizumab or placebo, both with docetaxel and prednisone. The time to pain progression measured by the Brief Pain Inventory-Short Form was a secondary end point. Health-related quality of life (HRQoL) scores, including disease-related symptoms, assessed by the Functional Assessment of Cancer Therapy-Prostate and EuroQol five-dimension five-level were prespecified exploratory end points.

KEY FINDINGS AND LIMITATIONS

The PRO analysis set comprised 1028 patients; the median follow-up was 22.7 mo from baseline until database cutoff (June 20, 2022). The median time to pain progression was 21.1 mo (95% confidence interval [CI] 13.7 to not reached [NR]) and NR (95% CI 13.8-NR) in the pembrolizumab and placebo arms, respectively (hazard ratio 1.05; 95% CI 0.77-1.43). Changes from baseline in PRO end points were similar between treatment arms and remained generally stable throughout the study. Limitations include a lack of formal hypothesis testing to detect between-arm differences in PROs.

CONCLUSIONS AND CLINICAL IMPLICATIONS

No meaningful differences in PROs were observed in patients with mCRPC treated with pembrolizumab plus chemotherapy versus chemotherapy alone. These findings indicate that adding an immune checkpoint inhibitor to chemotherapy does not positively or negatively impact HRQol in patients with mCRPC previously treated with NHAs.

Current landscape in first-line treatment of metastatic hormone sensitive prostate cancer: a cost-effectiveness focused review

Contemporary treatment of metastatic hormone-sensitive prostate cancer (mHSPC) has evolved significantly over the past decade with the introduction of upfront combination therapies (ie, ADT plus androgen receptor pathway inhibitors (ARPIs), with or without docetaxel), previously reserved for more advanced stages of the disease. However, the evidence is still controversial regarding the benefit of triple combinations beyond high volume disease (HVD) compared to double combinations, particularly those consisting of ADT + ARPIs. In addition, financial considerations regarding net benefits make these treatment regimens an unfavorable option from a cost-effectiveness standpoint, an element that becomes even more relevant in resource-limited contexts. Considering the lack of head-to-head trials for the direct comparison of triplets vs. ADT + ARPIs in different subgroups (as most evidence of specific combination superiority comes from indirect comparison in meta-analyses and the questionable cost-effectiveness profile triplets have shown), we propose that the current role of triplets is reserved for synchronous, HVD mHSPC in a resource-rich setting. Consequently, our work proposes a treatment algorithm that weighs the OS benefit according to the clinical risk of each patient subgroup and the availability of clinical resources. In this current scenario of abundant options, future research will focus on clarifying the selection of the most appropriate treatment for each patient according to their clinical characteristics and re-evaluating the cost-effectiveness of treatments as new drugs and generics emerge.

Darolutamide plus androgen-deprivation therapy: propensity score matching of ARASEC and historic clinical trial patients

Darolutamide plus androgen-deprivation therapy (ADT) with docetaxel is one of the standards of care for metastatic hormone-sensitive prostate cancer (mHSPC), based on the phase III ARASENS study. To provide the option to use darolutamide without docetaxel to meet patients' needs and preferences, the phase III placebo-controlled ARANOTE study was undertaken. Reflecting evolving treatment guidelines for mHSPC, the complementary US-based ARASEC study was designed with a single, prospectively-enrolled investigational arm (darolutamide plus ADT) and an ADT monotherapy arm derived from the previous phase III CHAARTED study. ARASEC was designed with the same eligibility criteria and assessments as CHAARTED, and patients were matched 1:1 using propensity scores calculated from key prognostic baseline variables: age, ECOG performance status, extent of disease, prior local therapy, Gleason score, and prostate-specific antigen level. ARASEC enrolled 223 patients who received darolutamide plus ADT, with 393 patients in the CHAARTED ADT control arm available for matching. Matching yielded 160 patients in each arm with minimal differences in prognostic variables between the matched groups, who will be compared to evaluate the efficacy and safety of darolutamide plus ADT in mHSPC. This novel study design may inform future single-arm trials with historical control arms, with potentially faster accrual and reduced costs.Clinical Trial Registration: NCT05059236.

Contemporary real-world treatment in metastatic hormone-sensitive prostate cancer: US, four European countries, and UK

AIM

To characterize contemporary global real-world metastatic hormone-sensitive prostate cancer (mHSPC) treatment, guideline concordance, trends, and potential trend drivers.

MATERIALS AND METHODS

Retrospective data from the Ipsos Global Oncology Monitor database for the United States, Germany, France, Spain, Italy, and the United Kingdom were used for descriptive analysis of mHSPC patients, treating physicians, and treatment utilization. Statistical testing of differences among treatment cohorts for the final study period was conducted.

RESULTS

Of 15,662 total mHSPC patients across countries (2019-2024), the 1404 patients from the most recent and relevant study period (August 2023-January 2024) had an average age of 72-74 years, good baseline functioning, high-risk prostate cancer features, and cardiometabolic conditions as top comorbidities. Treatment mostly occurred in hospital/institutional settings and urban locales by oncologists versus urologists. Monotherapy androgen deprivation therapy (mADT) use declined while use of novel androgen receptor inhibitor (nARI) combination therapies, especially doublets, increased. Concordance between real-world and guideline-recommended treatment varied by country, ranging from 43.8% to 61.6%.

CONCLUSIONS

Concordance with guidelines improved globally driven by nARIs. Persistent use of mADT, a non-guideline-recommended therapy, indicates physicians' concern about the safety and trade-offs with current options. New therapies delivering greater net benefits are needed, along with education on guideline adherence.

Adjuvant Docetaxel Versus Surveillance in Intermediate- or High-risk Prostate Cancer After Radical Curative Radiotherapy: Final Survival Results from the SPCG-13 Trial

The SPCG-13 trial investigated whether six cycles of adjuvant docetaxel (aDoc) improves survival in patients with intermediate- or high-risk prostate cancer after radical curative radiotherapy and androgen deprivation therapy. There was no difference in biochemical recurrence-free survival (primary endpoint) at 5-yr between the surveillance (SV) and aDoc arms. Here we report 10-yr survival data (planned secondary endpoint). Updated overall survival (OS) and metastasis-free survival data were available for 233 patients. There were no demographic differences between the original randomized cohort and the 10-yr survival population. Thus, this 10-yr sample is deemed representative of the original patient population. Median OS was 14.5 yr in the SV and was not reached in the aDoc arm. No significant difference in Kaplan-Meier survival emerged between the arms over time (log-rank test p = 0.154). Estimates of the 10-yr OS rate favored aDoc (77.4% vs 66.8%). Cox regression analysis revealed a trend towards worse OS for patients with a high Gleason score (GS; hazard ratio [HR] 1.925, 95% confidence interval [CI] 1.213-3.053; p = 0.005). A Cox model adjusted for GS risk revealed an OS HR of 0.776 (95% CI 0.508-1.187; p = 0.242) for aDoc versus SV. In conclusion, aDoc was associated with a slight, but not statistically significant, improvement in 10-yr OS, especially in the high-GS group. PATIENT SUMMARY: Our 10-year survival analysis for the SPCG-13 trial showed that six cycles of chemotherapy with docetaxel after radiotherapy and androgen deprivation therapy for intermediate- or high-risk localized prostate cancer did not significantly increase survival. Survival was worse for cancers with a high Gleason score, so docetaxel could be considered after a careful discussion of the benefits and harms of chemotherapy. Further trials are needed to investigate options for this group of patients.

Prostate Cancer: A Review

Importance

Prostate cancer is the most common nonskin cancer in men in the US, with an estimated 299 010 new cases and 35 250 deaths in 2024. Prostate cancer is the second most common cancer in men worldwide, with 1 466 680 new cases and 396 792 deaths in 2022.

Observations

The most common type of prostate cancer is adenocarcinoma (≥99%), and the median age at diagnosis is 67 years. More than 50% of prostate cancer risk is attributable to genetic factors; older age and Black race (annual incidence rate, 173.0 cases per 100 000 Black men vs 97.1 cases per 100 000 White men) are also strong risk factors. Recent guidelines encourage shared decision-making for prostate-specific antigen (PSA) screening. At diagnosis, approximately 75% of patients have cancer localized to the prostate, which is associated with a 5-year survival rate of nearly 100%. Based on risk stratification that incorporates life expectancy, tumor grade (Gleason score), tumor size, and PSA level, one-third of patients with localized prostate cancer are appropriate for active surveillance with serial PSA measurements, prostate biopsies, or magnetic resonance imaging, and initiation of treatment if the Gleason score or tumor stage increases. For patients with higher-risk disease, radiation therapy or radical prostatectomy are reasonable options; treatment decision-making should include consideration of adverse events and comorbidities. Despite definitive therapy, 2% to 56% of men with localized disease develop distant metastases, depending on tumor risk factors. At presentation, approximately 14% of patients have metastases to regional lymph nodes. An additional 10% of men have distant metastases that are associated with a 5-year survival rate of 37%. Treatment of metastatic prostate cancer primarily relies on androgen deprivation therapy, most commonly through medical castration with gonadotropin-releasing hormone agonists. For patients with newly diagnosed metastatic prostate cancer, the addition of androgen receptor pathway inhibitors (eg, darolutamide, abiraterone) improves survival. Use of abiraterone improved the median overall survival from 36.5 months to 53.3 months (hazard ratio, 0.66 [95% CI, 0.56-0.78]) compared with medical castration alone. Chemotherapy (docetaxel) may be considered, especially for patients with more extensive disease.

Conclusions and Relevance

Approximately 1.5 million new cases of prostate cancer are diagnosed annually worldwide. Approximately 75% of patients present with cancer localized to the prostate, which is associated with a 5-year survival rate of nearly 100%. Management includes active surveillance, prostatectomy, or radiation therapy, depending on risk of progression. Approximately 10% of patients present with metastatic prostate cancer, which has a 5-year survival rate of 37%. First-line therapies for metastatic prostate cancer include androgen deprivation and novel androgen receptor pathway inhibitors, and chemotherapy for appropriate patients.

Prevention of bicalutamide-induced breast events in patients with prostate cancer: a meta-analysis of randomized controlled trials

PURPOSE

This study aimed to quantitatively assess the effectiveness of tamoxifen, anastrozole, and radiotherapy in preventing bicalutamide-induced breast events-specifically gynecomastia and breast pain-in patients with prostate cancer.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted according to PRISMA-P guidelines. A comprehensive search was performed in PubMed, Scopus, and Web of Science for English-language studies without temporal restrictions. Studies were included if they involved prostate cancer patients treated with bicalutamide receiving preventive interventions (tamoxifen, anastrozole, or radiotherapy) compared to bicalutamide alone (or bicalutamide plus placebo/sham). Data extraction focused on the incidence of gynecomastia and breast pain, and study quality was assessed using the Jadad scale. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using fixed- or random-effects models, and heterogeneity was evaluated with the I² statistic. Publication bias was explored via funnel plots and the trim-and-fill method.

RESULTS

Nine RCTs met the inclusion criteria. Tamoxifen significantly reduced the risk of breast events by 82% (RR: 0.18, 95% CI: 0.08-0.38 for gynecomastia and RR: 0.18, 95% CI: 0.07-0.43 for breast pain). Radiotherapy reduced gynecomastia risk by 52% (RR: 0.48, 95% CI: 0.38-0.59) and breast pain by 34% (RR: 0.66, 95% CI: 0.48-0.90). Anastrozole did not show significant benefit.

CONCLUSION

Tamoxifen appears to be the most effective strategy for preventing bicalutamide-induced breast events, with radiotherapy serving as a viable alternative, and anastrozole offering no benefit. Further large-scale, high-quality studies are needed to confirm these findings and refine preventive treatment recommendations.

Real-world utilization patterns and survival in men with metastatic prostate cancer treated with Radium-223 in the United States

BACKGROUND

The treatment landscape for metastatic castration-resistant prostate cancer (mCRPC) has evolved since radium-223 (Ra-223) was approved in the United States (2013). We examined treatment patterns and real-world overall survival (rwOS) of men with mCRPC treated with Ra-223 in the modern treatment era.

METHODS

A retrospective cohort of men treated with Ra-223 was derived using private insurance data from the Komodo Health dataset from January 1, 2017 to June 30, 2022. Cox-regression analyses examined associations between Ra-223 use and rwOS with adjustment for covariates.

RESULTS

Of 1376 men, the median age was 68 years, 51% were White, and 89% had bone-only metastases. Overall, 17%, 35%, and 25% of men received Ra-223 as first-line, second-line, or third-line treatment for mCRPC, respectively. Thirty-six percent received Ra-223 as combination/layered therapy, mainly with enzalutamide, and 46% completed ≥5 cycles. Overall, median rwOS was 22.9 months. Median rwOS was longer in men who completed ≥5 Ra-223 cycles versus 1-4 cycles (30.3 versus 15.3 months) and combination/layered therapy versus monotherapy (26.6 versus 20.5 months). Combination/layered therapy and completion of ≥5 Ra-223 cycles were associated with 22% and 55% reductions in risk of death in adjusted analyses, respectively. Limitations include some clinical information not captured by claims databases.

CONCLUSIONS

Significant rwOS benefits were identified in men who received Ra-223 as an earlier line of therapy, received Ra-223 in combination with another therapy, and completed ≥5 Ra-223 cycles, underscoring the importance of Ra-223 in the current treatment landscape.

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.

Assessment of bone mineral density in men with de novo metastatic castration-sensitive prostate cancer treated with or without abiraterone acetate plus prednisone in the PEACE-1 phase 3 trial

AIM

Addition of abiraterone acetate plus prednisone (AAP) to androgen deprivation therapy (ADT) with or without docetaxel (D) improved overall survival in patients with de novo metastatic castration sensitive prostate cancer in the PEACE-1 trial. The protocol was amended during the course of the study to assess whether addition of AAP increases bone loss.

METHODS

Patients were randomized to receive either ADT + D with or without AAP. Bone mineral density (BMD) of the lumbar spine, femoral neck, and total hip were measured by dual X-ray absorptiometry at baseline, 6, 12, and 24 months (M). T-Scores and mean percent change in BMD values were assessed.

RESULTS

With 97 patients treated with AAP and 98 without, the median age was 65 years and 69 patients were ECOG 0 in each arm. Median baseline body mass index was 25.6 and 26.5 kg/m2 in patients treated with or without AAP, respectively. Ten and 30 % presented with baseline osteoporosis and osteopenia, respectively. Mean T scores and mean percent changes in BMD measured on three anatomic sites decreased during the first year of treatment in both arms, without difference between arms. At M24, a numerical two-fold increase in patients with osteoporosis was observed in the AAP arm.

CONCLUSIONS

This is the first prospective assessment of BMD in a randomized trial with an experimental treatment using AAP. Bone loss occurred rapidly in both arms, and addition of AAP did not increase bone loss significantly although a numerically higher rate of osteoporosis was observed at 2 years.

TRIAL REGISTRATION

NCT01957436.

Triplet therapy for metastatic castration-sensitive prostate cancer: Rationale and clinical evidence

Prostate cancer (PC) growth is hormone-dependent and it frequently develops distant metastases as disease progresses. Patients with metastatic castration-sensitive prostate cancer (mCSPC) initially respond to androgen deprivation therapy (ADT) but eventually become refractory and develop metastatic castration-resistant prostate cancer (mCRPC). Castration-resistance is associated with high lethality and metastases confer poor prognosis, therefore unmet needs in treatment for mCSPC remain high. So far, improvements in survival in mCSPC have been achieved by doublet combination therapy such as docetaxel or an androgen-receptor signaling inhibitor (ARSI) in addition to ADT. Further, recent phase 3 trials have shown that triplet therapy-a combination of ARSI, docetaxel, and ADT improves prognosis compared with docetaxel plus ADT in mCSPC. PC tumors manifest intra- and inter-tumoral heterogeneity at both the genetic and phenotypic level. As heterogeneity increases during sequential treatment and disease progression, it is reasonable to initiate combination therapy using drugs with different mechanisms of action early in the course of disease, such as mCSPC. Previous research about tumor heterogeneity and drug resistant mechanism support this rationale, as well as preclinical studies and real-world data provide the scientific evidence of benefit by combining ARSI and docetaxel. Here, we review the rationale and clinical evidence for triplet therapy in patients with mCSPC.

Comparison of two alternative sequences with cabazitaxel and 177Lu-PSMA-617 in metastatic castration-resistant prostate cancer: A retrospective multicenter study (LuCaS)

BACKGROUND

Cabazitaxel and 177Lu-PSMA-617 have been shown to improve survival in patients with metastatic castration-resistant prostate cancer (mCRPC) previously treated with docetaxel and androgen receptor pathway inhibitors (ARPI). we aimed to evaluate the impact of sequencing cabazitaxel and 177Lu-PSMA-617 on survival outcomes in patients with mCRPC.

PATIENTS AND METHODS

This is a retrospective, multicenter, cohort study which included patients with mCRPC who received sequential treatment with 177Lu-PSMA-617 and cabazitaxel between January 2015 and December 2023. Primary outcome was progression-free survival-2 (PFS-2) RESULTS: A total of 68 patients with mCRPC who received sequential 177Lu-PSMA-617 and cabazitaxel were included in the study. The primary outcome, progression-free survival-2 (PFS-2), was similar in patients treated with 177Lu-PSMA-617 first (LU-CA) and those receiving cabazitaxel (CA-LU) first (10.8 and 11.7 months, respectively; p = 0.422). The median overall survival (OS) was also similar in the LU-CA and CA-LU groups (16.6 and 19.9 months, respectively; p = 0.917). The objective response rate (ORR) for 177Lu-PSMA-617 was 23.1 % when used first and 16.1 % after cabazitaxel. ORR for cabazitaxel was 25.6 % and 31.3 % when used as the first agent and when used after 177Lu-PSMA-617, respectively.

CONCLUSIONS

In conclusion, treatment sequencing between cabazitaxel and 177Lu-PSMA-617 did not significantly affect survival outcomes in patients with mCRPC. These findings suggest that both drugs can be effectively integrated into the mCRPC treatment paradigm without concerns about the effect of sequencing. However, prospective data are needed to optimize sequencing strategies and explore their impact on specific patient subgroups for more personalized care.

Treatment of metastatic castration-resistant prostate cancer: review of current evidence and synthesis of expert opinions on radioligand therapy

Background

Despite the boom in the development of cancer management in the last decade, most patients with metastatic prostate cancer (PCa) eventually progress to metastatic castration-resistant PCa (mCRPC) and often require multiple lines of treatment. The treatment landscape of mCRPC has evolved rapidly in recent years, introducing various types of systemic therapies, including taxane-based chemotherapy, androgen receptor pathway inhibitors, bone-targeted radionuclides (e.g., radium-223), immune checkpoint inhibitors, poly(adenosine diphosphate [ADP]-ribose) polymerase (PARP) inhibitors, and radioligand therapies (RLTs) [e.g., a prostate-specific membrane antigen (PSMA) ligand labelled with 177Lu].

Methods

To help clinicians navigate the increasingly complex treatment landscape of mCRPC, this article reviews the evidence on different therapeutic regimens from pivotal trials. In addition, it reports on the results of a questionnaire developed and distributed by the Hong Kong Society of Uro-Oncology (HKSUO), with the aim of collecting the perspectives of specialists experienced in the treatment of advanced PCa in Hong Kong with regard to the clinical application of RLT, primarily [177Lu]Lu-PSMA-617/analogue therapy.

Results

A total of 43 questionnaire respondents (including clinical oncologists, urologists, nuclear medicine specialists, and medical oncologists) voted on 27 consensus questions divided into eight sections. Consensus or strong consensus (correspondingly ≥75% or ≥90% acceptance for an answer option) was reached for 10 questions. Subsequently, a panel of 13 local and overseas experts coordinated by the HKSUO discussed the voting results and provided further insights into certain questions.

Conclusion

The literature review, the voting results of the questionnaire, and the expert opinions are expected to facilitate better understanding of recent therapeutic advancements and the role of novel RLTs in the treatment of mCRPC among clinicians.

Medication related osteonecrosis (MRONJ) in the management of CTIBL in breast and prostate cancer patients. Joint report by SIPMO AND SIOMMMS

Background

Low-doses of bone modifying agents (LD-BMAs) compared to those used to treat bone metastases are used in breast or prostate cancer patients on adjuvant endocrine therapy to prevent Cancer Treatment Induced Bone Loss (CTIBL). Their use is associated with an increased risk of developing Medication-Related Osteonecrosis of the Jaw (MRONJ). However, there is not clarity about strategies aimed to minimize the MRONJ risk in cancer patients at different conditions as low- vs high-doses of BMA. This joint report from the Italian Societies of Oral Pathology and Medicine (SIPMO) and of Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases (SIOMMMS) aims to define the dental management of breast and prostate cancer patients with CTIBL under LD-BMAs, to reduce their risk to develop MRONJ.

Methods

This interdisciplinary SIPMO-SIOMMMS Expert Italian Panel reviewed the available international scientific literature and developed a set of recommendations to implement strategies of MRONJ prevention in breast (BC) and prostate cancer (PC) patients undertaking LD-BMAs to prevent CTIBL.

Results

The Expert Panel, after addressing some introductive topics (i.e., CTIBL and its management, pharmacology and pharmacodynamics of BMAs, definition and diagnosis of MRONJ), developed a joint report on the following five issues: a) prevention and dental management in cancer patients candidates to LD-BMAs, or under LD-BMAs; b) prophylactic drug holiday; c) MRONJ treatment; d) LD-BMAs therapeutic drug holiday; and e) restart of LD-BMA treatment after successful healing of MRONJ.Finally, ten key questions with answers were prepared and placed at the end of the document.

Conclusions

Despite obvious weaknesses of the available international literature, the Expert Panel recognized the need to tailor separate MRONJ preventive approach for breast and prostate cancer patients on adjuvant endocrine therapy who begin low-dose BMA therapy to prevent CTIBL and provided this practical guidance for bone specialists and oral healthcare providers. In view of a MRONJ risk for BC and PC patients receiving low-dose BMAs, which approximates that of patients with osteoporosis and other non-malignant diseases undergoing similar treatment schedules, the SIPMO-SIOMMMS Expert Panel recognizes the need for less stringent preventive strategies than those already developed for BC or PC patients with bone metastases taking HD-BMAs.

The Impact of Triptorelin on Hormone Levels in Human and Its Metabolite Confirmation Using Liquid Chromatography-Ion Trap/Time-of-Flight Mass Spectrometry (LC/MS-IT-TOF) and Liquid Chromatography-Orbitrap (LC-Orbitrap) for Doping Control Analysis

Triptorelin, a synthetic gonadotrophin-releasing hormone (GnRH), is mainly used in the clinical treatment of prostate cancer. The mechanism initially stimulates luteinizing hormone (LH) and testosterone secretion followed by suppression, resulting in a reduction in cancer progression. However, GnRHs are prohibited in doping control because of the indirect surge of LH and testosterone. Therefore, GnRH analog detection and confirmation are enforced by World Anti-Doping Agency (WADA) requirements. The effects of triptorelin on LH and endogenous steroid levels in urine and serum of five prostate cancer patients taking triptorelin for the first time were investigated and compared with leuprorelin. The samples were collected at 0.0 h, 3.0 h, 6.0 h, 1 month, and 3 months later after drug administration. The effect of triptorelin on LH levels was measured using a sandwich enzyme-linked immunoassay (ELISA). Testosterone and endogenous steroid levels were monitored using gas chromatography coupled with mass spectrometry (GC/MS). Triptorelin showed an advantage over leuprorelin on LH and testosterone suppression, which is preferable to use for prostate cancer treatment. In this study, triptorelin (5-10), a unique in vivo metabolite, was found in urine and serum and verified with synthetic triptorelin (5-10). The metabolite was analyzed using liquid chromatography combined with Orbitrap (LC-Orbitrap) and liquid chromatography coupled with ion trap/time-of-flight mass spectrometry (LC/MS-IT-TOF). When triptorelin levels are undetectable, the presence of triptorelin (5-10) in human urine can be used as evidence that triptorelin is being misused in doping control.

Defining the Position of [177Lu]Lu-PSMA Radioligand Therapy in the Treatment Landscape of Metastatic Castration-Resistant Prostate Cancer: A Meta-analysis of Clinical Trials

BACKGROUND

In recent years, theranostics has become a promising approach for treating metastatic castration-resistant prostate cancer (mCRPC), with trials investigating targeted radioligand therapy, particularly using prostate-specific membrane antigen labeled with lutetium-177 ([177Lu]Lu-PSMA). The proper position of [177Lu]Lu-PSMA in the therapeutic algorithm of mCRPC is yet to be identified.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a systematic review and meta-analysis of phase II/III randomized controlled trials to assess the efficacy of [177Lu]Lu-PSMA in treating mCRPC. Study endpoints included radiographic progression-free survival (rPFS), prostate-specific antigen-PFS, objective response rate, and overall survival.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Data were extracted according to the PRISMA statement. Summary hazard ratios (HRs) were calculated using random- or fixed-effects models. Statistical analyses were performed with RevMan software (v.5.2.3).

RESULTS

[177Lu]Lu-PSMA reduced the risk of rPFS (HR 0.55; 95% confidence interval [CI] 0.43-0.71; p < 0.00001) and prostate-specific antigen-PFS (HR 0.53; 95% CI 0.41-0.67; p < 0.00001), and improved the objective response rate compared with control therapies (response rate 3.55; 95% CI 1.91-6.60; p < 0.0001), whereas no significant cumulative effect on overall survival was documented (HR 0.92; 95% CI 0.65-1.31; p = 0.63). Notably, in a dedicated subanalysis, comparable effects on rPFS were observed when [177Lu]Lu-PSMA was compared with active therapy.

CONCLUSION

[177Lu]Lu-PSMA has a favorable impact on the radiographic and biochemical control of mCRPC and represents a potential treatment in a scenario where other valuable options are available. Further efforts are required to identify clinical and molecular markers necessary for proper patient stratification.

Circulating tumor DNA-guided treatment decision in metastatic castration-resistant prostate cancer patients: a cost-effectiveness analysis

Background

The androgen receptor pathway inhibitors (ARPI), abiraterone acetate and enzalutamide, are commonly used in first-line treatment of patients with metastatic castration-resistant prostate cancer (mCRPC). However, early resistance to ARPI treatment occurs frequently. Traditionally, the response is evaluated 3-6 months after the start of treatment. However, recent findings indicate that by detecting circulating tumor DNA (ctDNA) at baseline and 4 weeks after ARPI treatment initiation, patients with a nondurable response can be identified after 4 weeks of treatment, enabling an early switch to alternative treatments.

Objective

This study aims to evaluate the cost-effectiveness of ctDNA-guided treatment switch after 4 weeks of ARPI therapy in mCRPC patients compared to standard of care.

Design

A cost-effectiveness analysis.

Methods

A cost-effectiveness analysis was conducted by creating a Markov state transition model to simulate progression, mortality, and treatment costs over a 5-year time horizon comparing ctDNA-guided care versus standard of care. The outcomes measured were incremental treatment costs per life-years and quality-adjusted life-years (QALYs) gained.

Results

The analysis showed an incremental cost-effectiveness ratio of €65,400.86 per QALY gained and an incremental net monetary benefit of €2716.62. Thereby, the use of ctDNA-guided treatment was cost-effective in comparison to standard care in 74% of the simulations using a willingness-to-pay threshold of €80,000 per QALY gained.

Conclusion

Our study demonstrated the cost-effectiveness of using a ctDNA-guided early therapy switch in non-responders after only 4 weeks of first-line ARPI therapy in mCRPC patients. This paves the way for implementing ctDNA-guided treatment decisions in clinical practice.

Physician Reasons for or Against Treatment Intensification in Patients With Metastatic Prostate Cancer

Importance

Clarifying the underutilization of treatment intensification (TI) for metastatic castration-sensitive prostate cancer (mCSPC) may improve implementation of evidence-based medicine and survival outcomes.

Objective

To investigate physicians' beliefs about TI in mCSPC to understand the gap between evidence-based guidelines and clinical practice.

Design, Setting, and Participants

This survey study analyzed data from the Adelphi Real World retrospective survey, which comprised physician surveys that were linked to medical record reviews of US adult patients treated for mCSPC between July 2018 and January 2022.

Main Outcomes and Measures

The survey included questions on physician and practice demographics. Physicians completed patient record forms, based on patient medical records with information including patient demographics, clinical characteristics, and patient management. Physicians recalled reasons for prescribing decisions using 48 precoded and open-text responses. Bivariate and multivariable analyses assessed the likelihood of their patients receiving first-line TI; the main outcome was the likelihood of their patients receiving TI using odds ratios (ORs).

Results

In total, 617 male patients met the analysis criteria (mean [SD] age, 68.6 [8.1] years). Among these patients, 349 (56.6%) were Medicare beneficiaries. Overall, 430 (69.7%) did not receive first-line TI with androgen receptor pathway inhibitors and/or chemotherapy. The 107 US-based physicians' top reasons for treatment choice for their patients were tolerability concerns (TI: 121 [64.7%]; no TI: 252 [58.6%]; P = .18) and following guideline recommendations (TI: 115 [61.5%]; no TI: 230 [53.5%]; P = .08). In the bivariate analysis, physicians seeking to reduce prostate-specific antigen (PSA) by 75% to 100% were more likely to provide first-line TI compared with physicians who aimed to lower PSA by 0% to 49% (OR, 1.63 [95% CI, 1.04-2.56]; P = .03). In the multivariable analysis, patients whose physicians based treatment choice on guidelines were more likely to receive TI than patients whose physicians did not report this reason (OR, 3.46 [95% CI, 1.32-9.08]; P = .01).

Conclusions and Relevance

The findings of this study, which analyzed data from a medical records-linked clinical practice survey, indicated low rates of first-line TI for mCSPC despite guideline recommendations. Barriers to TI included lack of knowledge about guidelines and published efficacy and safety data. Physicians with greater PSA reduction goals were more likely to use TI. Physician education on treatment guidelines and clinical trial data, while raising expectations for PSA response, may increase rates of first-line TI in mCSPC.

PRIORITI: Phase 4 study of triptorelin or active surveillance in high-risk prostate cancer

AIM

To evaluate the efficacy and safety of triptorelin after radical prostatectomy (RP) in patients with negative lymph nodes.

METHODS

PRIORITI (NCT01753297) was a prospective, open-label, randomized, controlled, phase 4 study conducted in China and Russia. Patients with high-risk (Gleason score ≥ 8 and/or pre-RP prostate-specific antigen [PSA] ≥ 20 ng/mL and/or primary tumor stage 3a) prostate adenocarcinoma without evidence of lymph node or distant metastases were randomized to receive triptorelin 11.25 mg at baseline (≤ 8 weeks after RP) and at 3 and 6 months, or active surveillance. The primary endpoint was biochemical relapse-free survival (BRFS), defined as the time from randomization to biochemical relapse (BR; increased PSA > 0.2 ng/mL). Patients were monitored every 3 months for at least 36 months; the study ended when 61 BRs were observed.

RESULTS

The intention-to-treat population comprised 226 patients (mean [standard deviation] age, 65.3 [6.4] years), of whom 109 and 117 were randomized to triptorelin or surveillance, respectively. The median BRFS was not reached. The 25th percentile time to BRFS (95% confidence interval) was 39.1 (29.9-not estimated) months with triptorelin and 30.0 (18.6-42.1) months with surveillance (p = 0.16). There was evidence of a lower risk of BR with triptorelin versus surveillance but this was not statistically significant at the 5% level (p = 0.10). Chemical castration was maintained at month 9 in 93.9% of patients who had received triptorelin. Overall, triptorelin was well tolerated and had an acceptable safety profile.

CONCLUSION

BRFS was observed to be longer with triptorelin than surveillance, but the difference was not statistically significant.

PLAIN LANGUAGE SUMMARY

After a diagnosis of prostate cancer, one of the current treatments is surgical removal of the prostate and its cancer from the body. This is called radical prostatectomy. This may cure the person. Unfortunately, sometimes the tumor may have already spread into neighboring cells (lymph nodes). If this has happened, we know that giving people a chemical castration therapy to lower their levels of male sex hormones may reduce the risk of the cancer spreading further. This is achieved by giving people an androgen deprivation therapy (ADT), such as triptorelin (which is used in this study). What we do not yet know, and what we investigated in this study, is whether ADT can also benefit people who do not have signs that their cancer has already spread to the lymph nodes. Our study involved 226 men from China and Russia and investigated whether giving triptorelin for 9 months would lead to better outcomes compared with giving no additional treatment (active surveillance). All people in the study had radical prostatectomy but only half of them were given triptorelin in the following 8 weeks. The time frame of 8 weeks was used because this is the time needed to make sure that the surgery had gone well, and that no biological markers of cancer were still present in the person's blood (the marker is called prostate-specific antigen [PSA]). High levels of PSA are a sign that the prostate cancer has returned. People were monitored for 3 years with regular checks of their castration status and levels of the cancer marker (PSA). At the end of the study, we saw that it took longer for PSA levels to increase for people who had taken triptorelin than it did for those who had not had additional treatment, but the difference was not statistically significant. There were no unexpected safety concerns seen among the people taking triptorelin. Our findings are promising but more studies are needed to confirm if starting triptorelin shortly after surgery can benefit this group of people who have had their prostate cancer treated by radical prostatectomy and have no signs that their cancer has spread to the lymph nodes. [Correction added on 31th July 2024, after first online publication: Plain language summary is added in this version.].

Optimizing triple therapy in patients with metastatic hormone-sensitive prostate cancer

Triple therapy with docetaxel, androgen deprivation therapy (ADT) and androgen receptor pathway inhibitors (ARPIs) has demonstrated survival benefits in patients with metastatic hormone-sensitive prostate cancer (mHSPC), especially in those with high-risk disease. However, once the use of ADT and docetaxel is established, guidelines do not clearly specify which ARPI is most appropriate. In this work, a literature review to identify phase III clinical trials, systematic reviews, meta-analyses, and clinical practice guidelines on triple therapy in mHSPC was carried out. Evidence and recommendations were qualitatively reviewed to provide guidelines on the most suitable ARPI based on patient risk, disease volume, and nature of metastases (synchronous or metachronous). This review aims to update the previously published consensus on the optimal pharmacological treatment for mHSPC and to expose the opinions of hospital pharmacy, urology and medical and radiation oncology experts.

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.

Navigating therapeutic sequencing in the metastatic castration-resistant prostate cancer patient journey

BACKGROUND

Novel therapies for metastatic castration-resistant prostate cancer (mCRPC) have improved patient outcomes. However, there is uncertainty on the optimal selection of therapeutic agents for subsequent lines of therapy.

METHODS

We conducted a comprehensive review of published evidence from pivotal clinical trials and recent guidelines for the treatment of mCRPC. We further identify gaps in knowledge and areas for future research.

RESULTS

Key considerations to help guide treatment selection for patients with mCRPC include personal treatment history, individual clinical characteristics, symptoms, prognosis, availability of clinical trials, and other patient-specific factors. Genetic testing and prostate-specific membrane antigen-targeted imaging are important tools to evaluate candidacy for newer therapeutic options such as poly (ADP-ribose) polymerase inhibitors, alone or in combination with androgen receptor pathway inhibitors, and [177Lu]Lu-PSMA-617.

CONCLUSION

This article provides an overview of the evolving treatment landscape of mCRPC, discussing guideline-recommended treatment options and data from key clinical trials, while highlighting ongoing trials that may impact the future treatment landscape. Recommendations for optimal treatment sequencing based on individual patient factors are provided.

Correlation analyses of radiographic progression-free survival with clinical and health-related quality of life outcomes in metastatic castration-resistant prostate cancer: Analysis of the phase 3 VISION trial

BACKGROUND

[177Lu]Lu-PSMA-617 (177Lu-PSMA-617) plus protocol-permitted standard of care (SOC) prolonged overall survival (OS) and radiographic progression-free survival (rPFS) versus SOC in patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer (mCRPC) in the phase 3 VISION study, in addition to beneficial effects on symptomatic skeletal events (SSEs) and health-related quality of life (HRQOL).

METHODS

Post hoc analyses used the full analysis set from the VISION study (N = 831) overall and by randomized treatment arm (177Lu-PSMA-617 plus SOC, n = 551; SOC, n = 280). Correlations were determined between OS and rPFS and between rPFS or OS and time to SSE or to worsening HRQOL (Functional Assessment of Cancer Therapy-Prostate [FACT-P] and 5-level EQ-5D [EQ-5D-5L]). Correlation analyses used an iterative multiple imputation copula-based approach (correlation coefficients [rho] of <0.3 were defined as weak, ≥0.3 and <0.5 as mild, ≥0.5 and <0.7 as moderate, and ≥0.7 as strong).

RESULTS

In the overall population, rPFS correlated strongly with OS (rho, ≥0.7). Correlations between rPFS or OS and time to SSE without death were weak or mild. Time to worsening in the FACT-P total score and emotional and physical well-being domains correlated mildly or moderately with rPFS and moderately with OS. Correlation coefficients for time-to-worsening EQ-5D-5L scores were mild to moderate for both rPFS and OS. Correlation coefficients were similar between treatment arms.

CONCLUSIONS

In this analysis of the VISION study, rPFS correlated strongly with OS but not with time to SSE or worsening HRQOL. These findings require further investigation.

Activity of Lutetium-177 Prostate-specific Membrane Antigen and Determinants of Outcomes in Patients with Metastatic Castration-resistant Prostate Cancer Previously Treated with Cabazitaxel: The PACAP Study

BACKGROUND

Both cabazitaxel and lutetium-177 prostate-specific membrane antigen (Lu-PSMA) improve survival in metastatic castration-resistant prostate cancer (mCRPC) after an androgen receptor pathway inhibitor and docetaxel, but there are limited data regarding Lu-PSMA activity after cabazitaxel.

OBJECTIVE

To assess the activity of Lu-PSMA and determinants of outcomes after cabazitaxel in mCRPC.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis was conducted of consecutive mCRPC patients from eight European centers treated with Lu-PSMA after cabazitaxel.

INTERVENTION

Lu-PSMA every 6-8 wk at a dose of 6-7.6 GBq.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was radiographic progression-free survival (rPFS). The secondary endpoints included time to prostate-specific antigen (PSA) progression (TTPSA), overall survival (OS), PSA decline, objective response rate (ORR), clinical benefit, and safety.

RESULTS AND LIMITATIONS

Of 126 patients, 68% had International Society of Urological Pathology (ISUP) grade 4-5 disease, 21% had visceral metastases, and 7% had lymph node disease only. DNA damage repair (DDR) alterations were detected in 11/50 (22%) patients with available testing. Patients received a median number of 3 Lu-PSMA cycles (interquartile range 2-4). With a median follow-up of 12.0 mo, the median rPFS was 4.4 mo (95% confidence interval [CI] 3.2-5.4), TTPSA 3.5 mo (95% CI 3.0-4.6), and OS 8.9 mo (95% CI 6.5-12.7). The ORR was 35%, and 55 patients (44%) experienced a PSA decline of ≥50%. The time to castration resistance of <12 mo was associated with shorter rPFS (p = 0.01). A similar trend was observed for ISUP grade 4-5 (p = 0.08), and baseline positron-emission tomography parameters including PSMA mean standardized uptake value (SUV) and maximum SUV (respectively, p = 0.06 and 0.05). The duration of previous cabazitaxel or DDR status did not impact outcomes. Patients experiencing a PSA decline of ≥ 50% on therapy demonstrated longer rPFS, TTPSA, and OS (all p < 0.0001). Limitations include retrospective data collection and investigator-based rPFS assessment.

CONCLUSIONS

Lu-PSMA demonstrated a substantial PSA decline but limited rPFS after cabazitaxel in a real-life setting. Adverse baseline characteristics, baseline positron-emission tomography parameters, and quality of PSA response may help identify patients less likely to benefit from Lu-PSMA.

PATIENT SUMMARY

Lutetium-177 prostate-specific membrane antigen (Lu-PSMA) improved outcomes in patients with castration-resistant prostate cancer, but there are limited data about its activity after cabazitaxel, a chemotherapy that is also the standard of care in this setting. We conducted a study across eight European centers and showed substantial responses on Lu-PSMA after cabazitaxel, although activity was short lived in a heavily pretreated population. Our findings prompt for real-life evaluation of Lu-PSMA in earlier settings to define the best therapeutic sequence.

Androgen receptor modulatory miR-1271-5p can promote hormone sensitive prostate cancer cell growth

In most patients with advanced prostate cancer treated with hormonal therapy, androgen independence eventually emerges, leading to death. Androgen receptor signalling remains an important prostate cancer driver, even in the advanced disease stage. MicroRNAs (miRs), non-coding RNAs that regulate gene expression by inhibiting translation and/or promoting degradation of target mRNAs, can act as tumour suppressors or "oncomiRs" and modulate tumour growth. Because of their stability in tissues and in circulation, and their specificity, microRNAs have emerged as potential biomarkers, as well as therapeutic targets in cancer. We identified miR-1271-5p as an androgen receptor modulatory microRNA and we show it can promote hormone sensitive prostate cancer cell growth. Inhibition or overexpression of miR-1271-5p levels affects prostate cancer cell growth, apoptosis and expression of both androgen receptor target genes and other genes that are likely direct targets, dependent on androgen receptor status, and tumour stage. We conclude that miR-1271-5p has the potential to drive progression of hormone-dependent disease and that the use of specific inhibitors of miR-1271-5p may have therapeutic potential in prostate cancer.

Feasibility of Indirect Treatment Comparisons Between Niraparib Plus Abiraterone Acetate and Other First-Line Poly ADP-Ribose Polymerase Inhibitor Treatment Regimens for Patients with BRCA1/2 Mutation-Positive Metastatic Castration-Resistant Prostate Cancer

INTRODUCTION

Poly(ADP-ribose) polymerase inhibitors (PARPi) are a novel option to treat patients with metastatic castration-resistant prostate cancer (mCRPC). Niraparib plus abiraterone acetate and prednisone (AAP) is indicated for BRCA1/2 mutation-positive mCRPC. Niraparib plus AAP demonstrated safety and efficacy in the phase 3 MAGNITUDE trial (NCT03748641). In the absence of head-to-head studies comparing PARPi regimens, the feasibility of conducting indirect treatment comparisons (ITC) to inform decisions for patients with first-line BRCA1/2 mutation-positive mCRPC has been explored.

METHODS

A systematic literature review was conducted to identify evidence from randomized controlled trials on relevant comparators to inform the feasibility of conducting ITCs via network meta-analysis (NMA) or population-adjusted indirect comparisons (PAIC). Feasibility was assessed based on network connectivity, data availability in the BRCA1/2 mutation-positive population, and degree of within- and between-study heterogeneity or bias.

RESULTS

NMAs between niraparib plus AAP and other PARPi regimens (olaparib monotherapy, olaparib plus AAP, and talazoparib plus enzalutamide) were inappropriate due to the disconnected network, differences in trial populations related to effect modifiers, or imbalances within BRCA1/2 mutation-positive subgroups. The latter issue, coupled with the lack of a common comparator (except for olaparib plus AAP), also rendered anchored PAICs infeasible. Unanchored PAICs were either inappropriate due to lack of population overlap (vs. olaparib monotherapy) or were restricted by unmeasured confounders and small sample size (vs. olaparib plus AAP). PAIC versus talazoparib plus enzalutamide was not possible due to lack of published arm-level baseline characteristics and sufficient efficacy outcome data in the relevant population.

CONCLUSION

The current randomized controlled trial evidence network does not permit robust comparisons between niraparib plus AAP and other PARPi regimens for patients with 1L BRCA-positive mCRPC. Decision-makers should scrutinize any ITC results in light of their limitations. Real-world evidence combined with clinical experience should inform treatment recommendations in this indication.

Treatments for Patients with Metastatic Castration-resistant Prostate Cancer Who Previously Received Triplet Therapy at the Metastatic Hormone-sensitive Stage

The level of evidence for the management of prostate cancer progressing after triplet therapy is currently low. Molecular profiling of patients and enrolment in clinical trials are strongly recommended.

Metastatic Hormone-Sensitive Prostate Cancer and Combination Treatment Outcomes: A Review

Importance

Metastatic hormone-sensitive prostate cancer is currently an incurable disease. Despite a high response rate to androgen-deprivation therapy, most cases progress to castration-resistant disease, the terminal phase. This review provides a summary of the most recent evidence for current and emerging management strategies, including treatment intensification with combinations of therapies. It also provides recommendations on applying the evidence in clinical practice to encourage appropriate treatment to improve survival outcomes among patients with metastatic hormone-sensitive prostate cancer.

Observations

Androgen-deprivation therapy is the backbone of treatment for metastatic hormone-sensitive prostate cancer; however, it is insufficient alone to provide sustained disease control and long-term survival. Addition of an androgen receptor pathway inhibitor and/or docetaxel significantly improves survival, as demonstrated by several international phase 3 randomized clinical trials. Triplet therapy composed of androgen-deprivation therapy plus an androgen receptor pathway inhibitor plus docetaxel has been shown to improve overall survival over androgen-deprivation therapy plus docetaxel. In the ARASENS trial (darolutamide), the hazard ratios (HRs) were 0.68 (95% CI, 0.57-0.80) in the overall population; 0.71 (95% CI, 0.59-0.85) and 0.61 (95% CI, 0.35-1.05) in patients with de novo and recurrent disease, respectively; 0.69 (95% CI, 0.57-0.82) and 0.72 (95% CI, 0.41-1.13) in patients with high-volume and low-volume disease, respectively; and 0.71 (95% CI, 0.58-0.86) and 0.62 (95% CI, 0.42-0.90) in patients with high-risk and low-risk disease, respectively. In the PEACE-1 trial (abiraterone acetate + prednisone), the HRs were 0.75 (95% CI, 0.59-0.95; all de novo) in the overall population and 0.72 (95% CI, 0.55-0.95) and immature in the high-volume and low-volume subgroups, respectively. In the ENZAMET trial (enzalutamide), the HRs were 0.82 (95% CI, 0.63-1.06) in the overall population; 0.73 (95% CI, 0.55-0.99) and 1.10 (95% CI, 0.65-1.86) in the de novo and recurrent subgroups, respectively; and 0.87 (95% CI, 0.66-1.17) and 0.61 (95% CI, 0.33-1.10) in the high-volume and low-volume subgroups. Combination regimens are generally well tolerated, with adverse effects dependent on the profiles of the component drugs.

Conclusions and relevance

The findings of this review show compelling evidence from phase 3 randomized clinical trials in favor of initiating triplet combination therapy for patients with metastatic hormone-sensitive prostate cancer for the best overall survival. Patients who are eligible for chemotherapy should be offered androgen-deprivation therapy plus an androgen receptor pathway inhibitor plus docetaxel, particularly patients with high-volume, high-risk, or de novo metastatic disease.

Somatic Tumor Testing in Prostate Cancer: Experience of a Tertiary Care Center Including Pathologist-Driven Reflex Testing of Localized Tumors at Diagnosis

Somatic tumor testing in prostate cancer (PCa) can guide treatment options by identifying clinically actionable variants in DNA damage repair genes, including acquired variants not detected using germline testing alone. Guidelines currently recommend performing somatic tumor testing in metastatic PCa, whereas there is no consensus on the role of testing in regional disease, and the optimal testing strategy is only evolving. This study evaluates the frequency, distribution, and pathologic correlates of somatic DNA damage repair mutations in metastatic and localized PCa following the implementation of pathologist-driven reflex testing at diagnosis. A cohort of 516 PCa samples were sequenced using a custom next-generation sequencing panel including homologous recombination repair and mismatch repair genes. Variants were classified based on the Association for Molecular Pathology/American Society of Clinical Oncology/College of American Pathologists guidelines. In total, 183 (35.5%) patients had at least one variant, which is as follows: 72 of 516 (13.9%) patients had at least 1 tier I or tier II variant, whereas 111 of 516 (21.5%) patients had a tier III variant. Tier I/II variant(s) were identified in 27% (12/44) of metastatic biopsy samples and 13% (61/472) of primary samples. Overall, 12% (62/516) of patients had at least 1 tier I/II variant in a homologous recombination repair gene, whereas 2.9% (10/516) had at least 1 tier I/II variant in a mismatch repair gene. The presence of a tier I/II variant was not significantly associated with the grade group (GG) or presence of intraductal/cribriform carcinoma in the primary tumor. Among the 309 reflex-tested hormone-naive primary tumors, tier I/II variants were identified in 10% (31/309) of cases, which is as follows: 9.2% (9/98) GG2; 9% (9/100) GG3; 9.1% (4/44) GG4; and 13.4% (9/67) GG5 cases. Our findings confirm the use of somatic tumor testing in detecting variants of clinical significance in PCa and provide insights that can inform the design of testing strategies. Pathologist-initiated reflex testing streamlines the availability of the results for clinical decision-making; however, pathologic parameters such as GG and the presence of intraductal/cribriform carcinoma may not be reliable to guide patient selection.

Treatment patterns and outcomes in metastatic castration-resistant prostate cancer patients with and without somatic or germline alterations in homologous recombination repair genes

BACKGROUND

Although germline BRCA mutations have been associated with adverse outcomes in prostate cancer (PC), understanding of the association between somatic/germline alterations in homologous recombination repair (HRR) genes and treatment outcomes in metastatic castration-resistant PC (mCRPC) is limited. The aim of this study was to investigate the prevalence and outcomes associated with somatic/germline HRR alterations, particularly BRCA1/2, in patients initiating first-line (1L) mCRPC treatment with androgen receptor signalling inhibitors (ARSi) or taxanes.

PATIENTS AND METHODS

Data from 729 mCRPC patients were pooled for CAPTURE from four multicentre observational studies. Eligibility required 1L treatment with ARSi or taxanes, adequate tumour samples and biomarker panel results. Patients underwent paired normal and tumour DNA analyses by next-generation sequencing using a custom gene panel including ATM, BRCA1, BRCA2, BRIP1, CDK12, CHEK2, FANCA, HDAC2, PALB2, RAD51B and RAD54L. Patients were divided into subgroups based on somatic/germline alteration(s): with BRCA1/2 mutations (BRCA); with HRR mutations except BRCA1/2 (HRR non-BRCA); and without HRR alterations (non-HRR). Patients without BRCA1/2 mutations were classified as non-BRCA. Radiographic progression-free survival (rPFS), progression-free survival 2 (PFS2) and overall survival (OS) were assessed.

RESULTS

Of 729 patients, 96 (13.2%), 127 (17.4%) and 506 (69.4%) were in the BRCA, HRR non-BRCA and non-HRR subgroups, respectively. BRCA patients performed significantly worse for all outcomes than non-HRR or non-BRCA patients (P < 0.05), while PFS2 and OS were significantly shorter for BRCA than HRR non-BRCA patients (P < 0.05). HRR non-BRCA patients also had significantly worse rPFS, PFS2 and OS than non-HRR patients. Exploratory analyses suggested that for BRCA patients, there were no significant differences in outcomes associated with 1L treatment choice (ARSi or taxanes) or with the somatic/germline origin of the alterations.

CONCLUSIONS

Worse outcomes were observed for mCRPC patients in the BRCA subgroup compared with non-BRCA subgroups, either HRR non-BRCA or non-HRR. Despite its heterogeneity, the HRR non-BRCA subgroup presented worse outcomes than the non-HRR subgroup. Screening early for HRR mutations, especially BRCA1/2, is crucial in improving mCRPC patient prognosis.

Evaluating relugolix for the treatment of prostate cancer in real-world settings of care: the OPTYX study protocol

OPTYX is a multi-center, prospective, observational study designed to further understand the actual experience of patients with advanced prostate cancer treated with relugolix (ORGOVYX®), an oral androgen deprivation therapy (ADT), by collecting clinical and patient-reported outcomes from routine care settings. The study aims to enroll 1000 consented patients with advanced prostate cancer from community, academic and government operated clinical practices across the USA. At planned timepoints, real-world data analysis on treatment patterns, adherence and safety as well as health outcomes and health-related quality-of-life (HRQOL) after treatment discontinuation will be published in scientific peer-reviewed journals and presented at relevant conferences. This study will provide real-world data for practitioners and researchers in their understanding of the safety and effectiveness of relugolix. Clinical Trial Registration: NCT05467176 (ClinicalTrials.gov).

Case report: Exceptional and durable response to Radium-223 and suspension of androgen deprivation therapy in a metastatic castration-resistant prostate cancer patient

Despite the development of new therapies in the last few years, metastatic prostate cancer (PCa) is still a lethal disease. Radium-223 (Ra-223) is approved for patients with advanced castration-resistant prostate cancer (CRPC) with bone metastases and no visceral disease. However, patients' outcomes are heterogenous, and there is lack of validated predictive biomarkers of response, while biomarkers for early identification of patients who benefit from treatment are limited. This case report describes a remarkable and durable response to Ra-223 in a CRPC patient with bone metastases who had rapidly progressed to many previous therapies; this response is now lasting for 5 years even after having stopped backbone androgen deprivation therapy (ADT). Here, we present the clinical course of this exceptional response, as well as comprehensive genomic and histopathology analyses on sequential biopsies acquired before and after therapy. Additionally, we review current knowledge on predictive and response biomarkers to Ra-223 in metastatic prostate cancer.

Predictive Value and Therapeutic Significance of Somatic BRCA Mutation in Solid Tumors

Ten percent of patients with breast cancer, and probably somewhat more in patients with ovarian cancer, have inherited germline DNA mutations in the breast and ovarian cancer genes BRCA1 and BRCA2. In the remaining cases, the disease is caused by acquired somatic genetic and epigenetic alterations. Targeted therapeutic agents, such as poly ADP-ribose polymerases (PARP) inhibitors (PARPi), have emerged in treating cancers associated with germline BRCA mutations since 2014. The first PARPi was FDA-approved initially for ovarian cancer patients with germline BRCA mutations. Deleterious variants in the BRCA1/BRCA2 genes and homologous recombination deficiency status have been strong predictors of response to PARPi in a few solid tumors since then. However, the relevance of somatic BRCA mutations is less clear. Somatic BRCA-mutated tumors might also respond to this new class of therapeutics. Although the related literature is often controversial, recently published case reports and/or randomized studies demonstrated the effectiveness of PARPi in treating patients with somatic BRCA mutations. The aim of this review is to summarize the predictive role of somatic BRCA mutations and to provide further assistance for clinicians with the identification of patients who could potentially benefit from PARPi.

Standardized PSMA-PET Imaging of Advanced Prostate Cancer

Imaging of advanced prostate cancer is a challenging task, as it requires longitudinal characterization of disease extent in a standardized way to enable appropriate treatment selection and evaluation of treatment efficacy. In the last years, prostate-specific membrane antigen (PSMA)-PET/CT has become the reference standard examination for patients with advanced prostate cancer. Together with the rise of PSMA-PET, standardized frameworks for the reporting of image findings have been proposed, eg, the Prostate Cancer Molecular Imaging Standardized Evaluation (PROMISE) and the structured reporting system for PSMA targeted PET imaging (PSMA-RADS) framework. Therefore, recent evidence on PSMA-PET derived tumor volume as useful a biomarker for outcome prognostication and related frameworks will be discussed in the article. The PROMISE framework recommends quantifying the tumor volume per-organ system, which accounts for the fact that the location of the metastases greatly influence its biological aggressiveness. In addition, changes in PSMA-PET derived tumor volume have been shown to be promising biomarkers for response assessment. Limitations of PSMA-PET will also be discussed because the tumor volume might not always be suited for response assessment. As a pitfall of PSMA-based systems, decreasing PSMA-expression might erroneously be interpreted as response to therapy. Also, especially for patients with limited disease, the tumor volume might not be ideal for response assessment. Therefore, various frameworks have been introduced to objectively measure response to therapy with PSMA-PET. Amongst these, the PSMA-PET progression (PPP) criteria and the response evaluation criteria in PSMA (RECIP) are optimized for earlier and later phenotypes of advanced prostate cancer, respectively. Variables needed to determine PPP or RECIP outcome on PSMA-PET are recorded under the umbrella of PROMISE recommendations. In this article, various reporting and response assessment frameworks are explained and discussed. Also, recent evidence for the relevance of PSMA-PET biomarkers for clinical management and outcome prognostication are shown.

Dosimetric Comparison of Conventional Radiotherapy, Volumetric Modulated Arc Therapy, and Proton Beam Therapy for Palliation of Thoracic Spine Metastases Secondary to Breast or Prostate Cancer

The aim of this planning study was to compare the dosimetric outcomes of Volumetric Modulated Arc Therapy (VMAT), Proton Beam Therapy (PBT), and conventional External Beam Radiation Therapy (cEBRT) in the treatment of thoracic spinal metastases originating from breast or prostate cancer. Our study utilized data from 30 different treatment plans and evaluated target coverage and doses to vital organs at risk (OARs), such as the spinal cord, heart, esophagus, and lungs. The results showed that VMAT and PBT achieved superior target coverage and significantly lower doses to the spinal cord compared to cEBRT (target: median PTVD95%: 75.2 for cEBRT vs. 92.9 and 91.7 for VMAT (p < 0.001) and PBT (p < 0.001), respectively; spinal cord: median Dmax%: 105.1 for cEBRT vs. 100.4 and 103.6 for VMAT (p < 0.001) and PBT (p = 0.002), respectively). Specifically, VMAT was notable for its superior target coverage and PBT for significantly lower doses to heart, lungs, and esophagus. However, VMAT resulted in higher lung doses, indicating potential trade-offs among different techniques. The study demonstrated the relative advantages of VMAT and PBT over traditional RT in the palliative treatment of spinal metastases using conventional fractionation. These findings underscore the potential of VMAT and PBT to improve dosimetric outcomes, suggesting that they may be more suitable for certain patient groups for whom the sparing of specific OARs is especially important.

Phase II Trial Evaluating Olaparib Maintenance in Patients with Metastatic Castration-Resistant Prostate Cancer Responsive or Stabilized on Docetaxel Treatment: SOGUG-IMANOL Study

The SOGUG-IMANOL trial was a phase 2, uncontrolled, Spanish multicenter study to assess the effect of maintenance treatment with olaparib on radiographic progression-free survival (PFS) in patients with metastatic castration-resistant prostate cancer (mCRPC) who achieved partial or complete response or disease stabilization on docetaxel treatment and had a documented germline/somatic mutation in any of the homologous recombination repair (HRR) genes. Patients received olaparib 300 mg orally twice daily. From the screened population (n = 134), 26 (19.4%) somatic mutations were found, and 14 patients were included in the study. The median radiographic PFS was 11.1 (95%CI, 5.7 to 16.5) months. The median PSA-PFS was 3.5 (95%CI, 1.0 to 6.0) months, and the median clinical PFS was 14.7 (95%CI, 1.8 to 27.5 months). Clinical benefit was observed in 12 patients (85.7%, 95%CI 67.4% to 100%), including two patients with partial response and 10 with stable disease. Six patients reported grade 3-5 adverse events: asthenia (n = 3), anemia (n = 2) and neutropenia (n = 1). In this setting, olaparib has been shown to be an efficacious maintenance treatment in terms of radiographic PFS and clinical benefit, becoming a therapeutic option for some patients harboring an HRR gene mutation and in scenarios where further investigation is needed.

Darolutamide: A Review in Metastatic Hormone-Sensitive Prostate Cancer

Darolutamide (NUBEQA®) is an oral androgen receptor inhibitor (ARi) that is approved for the treatment of metastatic hormone-sensitive prostate cancer (mHSPC) in combination with androgen deprivation therapy (ADT) and docetaxel. In a pivotal trial, darolutamide plus ADT and docetaxel was superior to placebo plus ADT and docetaxel in prolonging the primary endpoint of overall survival, with improvements also reported in most secondary endpoints. Treatment with darolutamide plus ADT and docetaxel was associated with a manageable tolerability profile. Furthermore, the adverse events reported with darolutamide plus ADT and docetaxel were generally consistent with the safety profiles previously reported for ADT and docetaxel. Darolutamide expands the availability of treatment options in mHSPC and may be useful as a treatment for high-volume disease (typically defined as ≥ 4 bone metastases with spread outside of the pelvis and vertebral column).