Alan Bryce, MD: Dr. Heath, let’s shift now to an exciting space in prostate cancer over the last several years in metastatic hormone-sensitive prostate cancer, mHSPC. We’ve had a tremendous amount of activity here, but to kick it off, could you speak to what are our treatment goals in this space? What should we be focused on in the first-line setting for mHSPC, and what’s the rationale of how we think through what we’re trying to achieve with systemic therapy?

Elisabeth Heath, MD, FACP: Absolutely. Talk about a rapidly changing space with lots of trials in it. The hormone-sensitive space is one where the buzzword is not de-intensification, but intensification, and sort of who’s doing it and who’s not doing it, and [in] what patient population. For many years, it’s been ADT [androgen deprivation therapy], and we were OK with that. Frankly, most of the patients at this stage of the game were seen in urology, and I think the urologists have taken care of these folks, most of whom have issues with urologic symptoms and have other reasons to come back and get their treatment. But since the recent advent of CHAARTED [NCT00309985] and then moving on to a whole host of other trials that we’ll get into, the way we think about it now is either you’re in bucket 1, where it’s single-agent ADT, or you’re in bucket 2, where it’s ADT plus an oral ABP—and then we have the triplet, which is ADT plus docetaxel and ABP. Suddenly things got complicated because you’re trying to explain this to the fellows or to others who are not in this space, and everyone’s head is spinning because you’re trying to integrate data that’s maturing all at the same time. Then you’re fine doing something one way and then 6 months later, you’re at a meeting and you go, nope, now it’s a whole different way. I think NCCN [National Comprehensive Cancer Network] has been helpful in responding to doing this in real time, so that’s terrific. Despite all of this, back to real-world data, we can talk all we want about what we think is intensification, but the real data shows it’s not happening. There are 2 different things happening at the same time: We need to be aware of the data, so you’re serving your patients to the best you can, and then it’s just about who is fit for what treatment and then being satisfied with that so you can set them up for what is to come in the CRPC [castration-resistant prostate cancer] state. That’s where this group of patients has taken a lot of energy and discussion for all of us to get right.

Alan Bryce, MD: Fair. To your point, we’ve had all these clinical trials showing improvement in overall survival; no question. Treatment intensification, whether doublet or triplet, gives improved survival and improved quality of life over ADT monotherapy, yet the real-world data is saying half of patients are getting ADT monotherapy. Hopefully, that’s shifting over time, but we should probably address it. In your opinion, when, if ever, is ADT monotherapy the right choice?

Elisabeth Heath, MD, FACP: I think it’s probably more frequent than what everybody in their academic silos are thinking because patients come with all sorts of comorbidities and their own wishes, as well as their own experience with chemotherapy and pills. When you bundle that all up together, we can cite all the data we want and then at the end they’re like, “OK, well, you can just keep all of that and I’ll just take my shot.” When you get down to the practical application, I always say it can’t be a Biology 101 lecture [where] we’re all pontificating for 1 hour, and they shut down 10 minutes into it and all they see is just blah, blah, blah, blah, blah; you must make it simple. We want to prolong your survival, but their point is it can’t be at all costs. Finding the niches is what we’re good at in this field. Then trying to make sure we convey it to everyone who maybe doesn’t see prostate cancer all day long, like all of us, so that they can see that person in their minds and go, “Oh yeah, this person is at this, and this is then the right approach.” So if we can do that, I think we’ll be successful.

Alan Bryce, MD: Absolutely. It’s always shared decision-making, and the patient’s going to tell us what is acceptable to them. I tell the fellows there is still the patient [for whom] ADT monotherapy is OK, but to me, that patient is the one [for whom], due to comorbidities, life expectancy is short. Let’s say it’s 2 years for heart disease. The point of treatment of the prostate cancer is to simply prevent bone pain and other symptoms. If overall survival’s not the goal, because that’s already compromised from other reasons, and all we’re trying to do is control symptoms for the short term, then I think ADT monotherapy is very appropriate. For everyone else, my default is to say we’re starting with intensification and then we have to justify why we’re downgrading if that’s what we’re going to do.

Transcript edited for clarity.