Dr Park on Patient and Disease Factors that Affect Treatment Decisions for mHSPC

“I evaluate patients for high-risk, high-volume disease. If they’re young and also have liver-metastatic disease, I consider triplet therapy based on the ARASENS study. On the other hand, for most of my patients, I consider doublet therapy, which is apalutamide plus ADT, or even darolutamide plus ADT, based on the ARANOTE study, if they’re [receiving] a blood thinner, such as Eliquis.”

Chandler Park, MD, FACP, genitourinary medical oncologist, Norton Cancer Institute, discusses patient characteristics, disease factors, and drug mechanisms of action that influence treatment decisions in metastatic hormone-sensitive prostate cancer (mHSPC).

The classification of mHSPC is guided by criteria established in landmark studies, such as the phase 2/3 STAMPEDE trial (NCT00268476), the phase 3 CHAARTED trial (NCT00309985), and the phase 3 LATITUDE trial (NCT01715285), Park begins. High-volume disease is defined by the presence of visceral metastases, such as those in the lungs or liver; or the presence of more than 3 bone lesions, with at least 1 lesion located outside the spine or pelvis, he explains. The definition of high-risk disease, per the LATITUDE trial, includes at least 2 of these 3 factors: a Gleason scores of 8 to 10, the presence of 3 or more bone lesions, and the presence of visceral metastases, he adds.

Patients with newly diagnosed synchronous metastatic prostate cancer often have a poor prognosis, typically surviving 3 to 4 years, Park says. High-risk disease features, such as liver metastases, warrant consideration for triplet therapy in younger patients, he reports. Triplet therapy in this context typically involves androgen deprivation therapy (ADT), a second-generation androgen receptor inhibitor, and docetaxel, as supported by findings from the phase 3 ARASENS trial (NCT02799602).

However, most patients with high-risk disease receive doublet therapy, which usually consists of ADT plus apalutamide (Erleada) or enzalutamide (Xtandi), according to Park. Off-label darolutamide (Nubeqa) use is sometimes considered in patients receiving anticoagulation therapy due to its lower risk of drug-drug interactions compared with apalutamide and enzalutamide, Park emphasizes.

A small subset of patients who are approximately 80 or 90 years of age with significant comorbidities and a limited life expectancy receive ADT alone, Park explains. This treatment approach minimizes the risk of developing treatment-related toxicities, he concludes.