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| Systemic treatment for metastatic prostate cancer |
Gwenaelle Gravis( )
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| Centre de Recherche en Cancerologie de Marseille (CRCM), Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France |
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Abstract The management of metastatic prostate cancer (mPCa) has changed over the past ten years. Several new drugs have been approved with significant overall survival benefits in metastatic castration resistant prostate cancer (PCa) including chemotherapy (docetaxel, cabazitaxel), new hormonal therapies (abiraterone, enzalutamide), Radium-223 and immunotherapy. The addition of docetaxel to androgen deprivation therapy (ADT) versus ADT alone in the castration sensitive metastatic setting has gained significant overall survival benefit particularly for high volume disease. More recently two phase III trials have assessed the efficacy of abiraterone plus prednisone plus ADT over ADT alone in newly high risk castrate sensitive mPCa. Determination of the appropriate treatment sequence using these therapies is important for maximizing the clinical benefit in castration sensitive and castration resistant PCa patients. Emerging fields are the identification of new subtypes with molecular characterization and new therapeutic targets.
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Received: 16 October 2018
Available online: 11 February 2019
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| Study | Agents | n | Indication | HR (95% CI) | OS | | Tax-327 [6] | Docetaxel + P vs Mitoxantrone + P | 1006 | mCRPC | 0.76 (0.62-0.94) | 18.9 vs. 16.5 | | D9901 and D9902 [27], [28] | Sipuleucel T vs. Po | 225 | mCRPC pre docetaxel | 1.5 (1.10-2.05) | 32.2 vs. 18.9 | | IMPACT [29] | Sipuleucel T vs. Po | 512 | mCRPC pre docetaxel | 0.78 (0.61-0.98) | 25.8 vs. 21.7 | | COU-AA-301 [17] | Abiraterone + P vs. P | 1195 | mCRPC post docetaxel | 0.65 (0.54-0.77) | 14.8 vs. 10.9 | | COU-AA-302 [18], [19] | Abiraterone + P vs. p | 1088 | mCRPC pre docetaxel | 0.75 (0.61-0.93) | NR vs. 27.2 | | AFFIRM [22] | Enzalutamide vs. Po | 1199 | mCRPC post docetaxel | 0.63 (0.53-0.75) | 18.4 vs. 13.6 | | PREVAIL [23] | Enzalutamide vs. Po | 1717 | mCRPC pre docetaxel | 0.71 (0.60-0.84) | 32.4 vs. 30.2 | | TROPIC [24] | Cabazitaxel + P vs. Mitoxantrone + P | 755 | mCRPC post docetaxel | 0.70 (0.59-0.83) | 15.1 vs. 12.7 | | ALSYMPCA [30] | Radium-223 vs. Po | Po921 | mCRPC pre docetaxel | 0.7 (0.55-0.88) | 14 vs. 11.2 | | FIRSTANA [25] | Cabazitaxel 25 mg/m2 (C25) vs. 20 mg/m2 (C20) vs. docetaxel 75 mg/m2 (D75) | 1168 | mCRPC pre docetaxel | C20 vs. D75 1.01 (0.85-1.20)
C25 vs. D75 0.97 (0.82-1.16) | 24.5 C20
25.2 C25
24.3 D75 | | PROSELICA [26] | Cabazitaxel 25 mg/m2 (C25) vs. 20 mg/m2 (C20) | 1200 | mCRPC post docetaxel | 1.024 | 13.4 vs. 14.5 |
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Phase III mCRPC.
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| DOCETAXEL + ADT vs. ADT | Abiraterone + prednisone + ADT vs. ADT | | GETUG-15 [8], [9] | CHAARTED [11], [12] | STAMPEDE [13], [34] | STAMPEDE [21] | LATITUDE [20] | | Period of inclusion | 10/2004-12/2008 | 07/2006-11/2012 | 10/2005-03/2013 | 11/2011-01/2014 | 02/2013-12/2014 | | n | 385 | 790 | 2962 (M0/M1) | 1917 (M0/M1) | 1199 | | ECOG, PS | | 0 | 357 (98%) | 549 (69.5%) | 662 (72%) ADT arm | 1489 (77.7%) | | | 1-2 | 9 (2%) | 241 (30.5%) | 225 (28%) ADT arm | 428 (22%) | NA | | Metastatic at diagnosis | 71% (272) | 73% (575) | 61% (1817) | 49% (941) | 100% (1199) | | Burden of metastases | | HVD | 48% (183) | 65% (513) | NA | NA | 100% (1199) | | LVD | 52% (202) | 35% (277) | NA | NA | 0 | | Gleason Score ≥8 | 56% | 61.2% | 64% ADT arm | 75% | 98% | | Number of cycles of Docetaxel/median duration of abiraterone + p | 9 | 6 | 6 + prednisone
10 mg/day | 23.7 months | NA | | Median follow-up (months) | 84 | 54 | 43 | 40 | 30.4 | | Median OS (months) ADT/ADT + D (or abiraterone + prednisone) | 48.6/62.1
HR 0.88 (0.68-1.14) | 47.2/57.6
HR: 0.73 (0.59-0.89) | 45/60
HR: 0.76 (0,62-0,92) | 3-year survival
76%/83%
HR: 0.63 (0.52-0.76) | 34.7/NR
HR: 0.62 (0.51-0.76) | | Median OS HVD (months) ADT/ADT + D | 35.1/39.8
HR: 0.78 (0.56-1.09) | 34.4/51.2
HR: 0.63 (0.50-0.79) | NA | NA | 34.7/NR
HR: 0.62 (0.51-0.76) | | Median OS LVD (months) ADT/ADT + D | 83.4/NR
HR: 1.02 (0.67-1.55) | NR/63.5
HR: 1.04 (0.70-1.55) | NA | NA | NA | | Median PFS (months) ADT/ADT + D (or abiraterone + prednisone) | 12.9/22.9
HR: 0.67 (0.54-0.84) | 11.7/19.4
HR: 0.61 (0.52-0.73) | M1: HR: 0.61 (0.53-0.71) | 3-year failure-free survival 45%/75% HR: 0.29 [0.25-0.34] | radiographic PFS 14.8/33.0 HR: 0.47 (0.39-0.55) |
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Phase III mCSPC.
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