Advanced prostate cancer treatment has seen an explosion of novel agents in the last 15 years, starting with chemotherapeutics and expanding further with the arrival of androgen receptor antagonists and checkpoint inhibitors.
At one time, androgen deprivation therapy (ADT) was the only option for treating metastatic prostate cancer. Using surgery or drugs such as leuprolide or goserelin, ADT halts the body’s production of testosterone.
“That was the foundation of treatment for years,” said Dr. David Penson, professor and chair of the Department of Urology at Vanderbilt University Medical Center. “If a patient had metastatic prostate cancer, we would give him ADT and maybe radiation to where the cancer spread. The ADT worked for a few years, but eventually it would stop working and the cancer would spread.”
The expansion of prostate cancer treatment options started with traditional chemotherapy. “First you had mitoxantrone,” Dr. Penson said. “Then came docetaxel, which prolonged survival by about three to four months .”
After that, the immunotherapy drug sipuleucel-T hit the market. “It also prolonged life by about four months,” Dr. Penson said.
Advances in the last five years have centered around the androgen receptor antagonists enzalutamide, apalutamide and darolutamide, and the hormone therapy drug, abiraterone.
In a new direction for prostate cancer care, ongoing studies like the TRoMbone trial are assessing whether there is a benefit to treating minimal metastatic disease both systemically and locally, using radiation or surgery.
“For a patient where the cancer has spread, for example to their back or lymph nodes, the thought was there is no benefit to treating the primary tumor,” Dr. Penson explained. “Now, what we’re finding is that for men who have minimal spread elsewhere in their body – one to three lesions – when we use these novel agents and treat the primary tumor at the same time, they do even better.”
“That’s a complete paradigm shift in the way we treat prostate cancer. It’s certainly not the standard of care at this point, but it’s a new concept being tested in trials.”Friday Letter Submission, Publish on February 21