Dr. Choudhury on Antiandrogen Treatment Selection in Nonmetastatic CRPC

Atish D. Choudhury, MD, PhD, co-director of the Prostate Cancer Center, senior physician, Dana-Farber Cancer Institute, and instructor in medicine, Harvard Medical School, discusses antiandrogen treatment selection in nonmetastatic castration-resistant prostate cancer (CRPC).

Darolutamide (Nubeqa), enzalutamide (Xtandi), and apalutamide (Erleada) have demonstrated similar overall survival benefits for men with nonmetastatic CRPC who are also continuing androgen deprivation therapy (ADT). Although each agent can be considered a reasonable option, some factors may aid in selecting among them, explains Choudhury.

First, it should be confirmed that the patient requires additional therapy with an antiandrogen, Choudhury says. Some patients with a longer prostate-specific antigen (PSA) doubling time may not need treatment intensification beyond ADT.

Conversely, patients with a shorter PSA doubling time should undergo novel PET imaging to determine whether sites of disease are visible, Choudhury says. Patients with focal disease should receive an antiandrogen with focal therapy to sites of disease, whereas patients who do not have sites of disease should receive an antiandrogen plus ADT until progression. 

There are no data to support whether discontinuing an antiandrogen is reasonable once a patient derives a prolonged response or whether these agents should be continued until disease progression, concludes Choudhury.