Disease Factors Can Support Intensification or Deescalation in HSPC

Che-Kai Tsao, MD, MS, system chief of solid tumor oncology at Northwell Health Cancer Institute, discusses the current state of treatment for metastatic hormone-sensitive prostate cancer (HSPC).

Although combination therapy is the standard of care, Tsao notes that many therapeutic options and real-world studies indicate that not all patients receive combination therapy. It is relevant to consider high-volume vs low-volume disease when deciding on treatment, which Tsao discussed with other oncologists recently when moderating a Case-Based Roundtable event.

Options such as androgen deprivation therapy (ADT) plus androgen receptor pathway inhibitor therapy (ARPI) as doublet therapy may be an option for certain patients, depending on disease volume and other factors, according to Tsao. Evaluating the level of disease may also require the use of biomarkers and clinical phenotypes.

Biomarkers such as homologous recombination deficiency (HRD) and prostate-specific membrane antigen (PSMA) can sway treatment decisions for this patient population. Tsao says there is a possibility of de-escalating therapy for appropriate responders to improve quality of life, which is why it is important to identify these disease factors.

TRANSCRIPTION

0:10 | The nice thing, as a prostate cancer medical oncologist and also for patients, is we’re now in a time where we have a lot of therapeutic options for metastatic HSPC. I do think it’s clear at this point that combination therapy should be a standard of care. But really, if you look at some of the more recent real-world studies, that is still not the case for a lot of patients in this country, and we have a lot more work to do on that to make sure that our patients get the combination therapy, no matter which one is chosen for them.

0:47 | We talked a lot about what high volume vs low volume means. Specifically, I think there is now a consensus that the triplet chemotherapy should mostly be reserved for patients with high-volume disease. That’s kind of a focus area that we discuss. But essentially, for patients with high-volume disease, we can still choose doublets of an ADT plus an ARPI or triplet therapy, and that decision depends on a number of patient disease and treatment factors. So we’re entering a time where we have so many great therapeutic options for patients, but that’s also evolving, because now we have the chance to use biomarkers and different clinical phenotypes.

1:34 | We have that opportunity to look at responses after starting a doublet therapy with an ARPI, to look at whether…we may want to require intensification with chemotherapy. There are genomic tests that we could use to...which are prognostic markers at this point, but very quickly we may see, for example, patients with HRD mutations may benefit from the addition of PARP inhibitors. With PSMAddition [NCT04720157], maybe some patients may benefit from the addition of lutetium Lu 177 [Pluvicto] in hormone-sensitive disease. What about AKT inhibitors? But what about a chance to de-escalate therapy with an appropriate response? There are a lot of therapeutic options that I think, as we continue to develop the different therapeutic approaches in these clinical trials, we will be able to help our patients balance the cancer control, as well as their quality of life.