Topic: Non-Metastatic Castration-Resistant Prostate Cancer

New Prescribing Information on Survival Benefit for Nubeqa® (Darolutamide) Approved

E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, interviews Neal D. Shore, MD, Medical Director for the Carolina Urologic Research Center in Myrtle Beach, about the recent FDA amendment to the package insert for NUBEQA®, or darolutamide. The amendment includes new information for patients with non-metastatic castration-resistant prostate cancer (nmCRPC) from the ARAMIS trial on overall survival and other endpoint data, including time to pain progression and time to the requirement for cytotoxic chemotherapy. Drs. Crawford and Shore discuss how the recent data demonstrating darolutamide’s overall survival benefit validates the previous use of metastasis-free survival as a surrogate for value. They also talk about the value of darolutamide for patients with nmCRPC who may not see much benefit to taking another medication. Drs. Crawford and Shore conclude by considering darolutamide’s future, mentioning the ARASENS trial looking at darolutamide’s benefits for patients with metastatic hormone-sensitive prostate cancer and discussing potential new research into darolutamide in the mCRPC space.

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Challenging Cases in Advanced Prostate Cancer: nmCRPC

R. Jonathan Henderson, MD, a urologist with Regional Urology, LLC, discusses an unusual case of non-metastatic castration-resistant prostate cancer (nmCRPC) with a panel featuring Laurence Klotz, MD, FRCSC, Daisaku Hirano, MD, and Michael S. Cookson, MD. The case in question involves an asymptomatic patient in his 70s who was successfully treated for localized prostate cancer and then, ten years later, was treated with cryotherapy for recurrent cancer, after which point cancer stopped appearing in imaging, but the patient’s PSA rapidly rose even as he was treated with abiraterone. Drs. Klotz, Hirano, and Cookson discuss whether it is appropriate to give such treatments to a persistently asymptomatic patient and note that his high PSA could be a response to abiraterone. They also consider the possibility that advanced imaging techniques like PSMA-PET would reveal that the man does have metastases and ponder which of the approved treatments for nmCRPC might suit this patient best.

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PROfound Trial Shows Increased rPFS in mCRPC Patients with BRCA1, BRCA2, and ATM Mutations

Maha H. Hussain, MD, FACP, FASCO, and Celestia S. Higano, MD, discuss the PROfound Trial, which demonstrated increased radiographic progression-free survival (rPFS) with the use of olaparib for mCRPC patients displaying the genetic mutations BRCA1, BRCA2, and ATM. Dr. Hussain outlines previous research of genetic mutations in mCRPC that led to this study, the study design and rationale of using two cohorts with specific mutations (BRCA1, BRCA2, and ATM) and non-specific mutations (other genetic alterations), and results that demonstrate promise for gene-targeted therapies in the future.

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Response to Apalutamide Among Patients With Nonmetastatic Castration-Resistant Prostate Cancer (nmCRPC) From SPARTAN by DECIPHER Genomic Classifier Score

Fred Saad, MD, FRCS, presents findings from an exploratory analysis he led and presented at the American Urological Association’s 2019 Annual Meeting. The study evaluated the association between DECIPHER genomic classifier (GC) score and metastasis-free survival following apalutamide treatment in nonmetastatic castrate-resistant prostate cancer (nmCRPC) patients included in the SPARTAN study.

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Navigating the M0 Space

E. David Crawford, MD, reviews the historical developments in androgen deprivation therapy (ADT) for prostate cancer and the emergence of the non-metastatic castration-resistant, or M0, prostate cancer. He then describes future directions for treatment options for these patients with a focus on androgen pathway inhibitors.

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Navigating the M0 Space- Results of RADAR III

Neal D. Shore, MD, reviews the recently-published guidelines focused on next generation imaging for early detection of disease progression in M0 prostate cancer in the Prostate Cancer Radiographic Assessments for Detection of Advanced Recurrence III (RADAR III). He also reviews the goals and conclusions from RADAR I and II.

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Testosterone Replacement and Focal Therapy

Mohit Khera, MD, MBA, MPH, reviews the literature surrounding the safety of testosterone replacement therapy (TRT) following prostate cancer treatment, including after brachytherapy, EBRT, and radical prostatectomy (RP). He also discusses the concept of bipolar androgen therapy (BAT) and the importance of TRT for erectile preservation post-RP.

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Sequencing of Adjuvant Therapies

Daniel P. Petrylak, MD, provides his perspective on optimal drug sequencing for castration resistant prostate cancer (CRPC) and metastatic CRPC (mCRPC). He reviews the literature regarding available and emerging immunotherapeutic, hormonal, cytotoxic, and DNA damaging treatment options and when to time each drug.

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Incorporating New PET Imaging and Theranostic Approaches into Prostate Cancer Practice | Interesting Cases

Robert R. Flavell, MD, offers an introductory overview of theranostics and advances in nuclear imaging and therapies, especially prostate-specific membrane antigen (PSMA) agents. Subsequently, he leads a panel with Susan F. Slovin, MD, PhD, E. David Crawford, MD, and Phillip J. Koo, MD in reviewing four distinct prostate cancer cases, sharing their thoughts and recommendations with regard to use of recently developed imaging agents and therapies.

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M0 Space and The SPARTAN Trial

Eric J. Small, MD, defines nonmetastatic castration-resistant prostate cancer, or M0 disease. He then discusses the design, implementation, and results of the SPARTAN trial, which he presented at the 2018 Genitourinary Cancers Symposium. The study tested the efficacy of apalutamide in men with M0 disease.

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