Evolving Standard of Care for mHSPC Prompts Interest in Deescalation

Che-Kai Tsao, MD, MS, system chief of Solid Tumor Oncology at Northwell Health Cancer Institute, discusses new approaches that could change the standard of care for metastatic hormone-sensitive prostate cancer (mHSPC).

Tsao suggests that intermittent androgen deprivation therapy (ADT), which has been investigated for decades, might be more valuable now that combining ADT and androgen receptor pathway inhibitors (ARPIs) is the standard of care in the hormone-sensitive setting. Trials are now investigating whether patients with a response to ADT and APRI can be spared from long-term continuous ADT.

Another key question that is developing now is the expanding definition of oligometastatic disease that can be treated with radiation therapy. Tsao says the increased number of sites considered oligometastatic raises questions of whether to treat these patients aggressively with ADT, ARPI, and chemotherapy or only doublet therapy. Ongoing randomized trials that will report results over the next few years could shed light on how to optimize care for these patients.

TRANSCRIPTION

0:10 | I think my own question is always, who can we spare with metastatic prostate cancer from androgen deprivation therapy? For decades and decades, it's considered the backbone of therapy. But we for many years had considered an intermittent ADT approach, which in some ways are just as good as continuous ADT. But now, as we enter combination therapy, can we use a response to spare patients from having long term ADT by either employing an intermittent ADT but a continuous ARPI approach, or an intermittent ADT plus ARPI approach? So I think those are good questions that I think the ongoing clinical trials will help us answer in the next few years.

0:58 | So I think that's an area. I think another area is the treatment of oligometastatic disease. The definition of oligometastatic disease has really evolved. Initially, it's defined as less than 3 sites of disease that can be targeted, then 5 sites. Now clinical trials include up to 10 sites of PET-positive disease as oligometastatic disease, where you could do radiation. Do we treat these patients aggressively with triplet therapy? Do we treat these patients with just doublet therapy? In patients who presents with de novo metastatic prostate cancer, can we radiate the prostate and their metastatic sites. But do we continue their ADT/ARPI indefinitely or for a fixed period of time?

1:43 | Those are all evolving questions where a number of clinical trials are trying to answer them at this point. We don't have all the answers right now. At the same time, I'm excited to see the publishing of some of the randomized studies that we'll be looking at in the next few years to answer some of those questions.