47IN - How should we use cytotoxic chemotherapy in the treatment of castration-resistant prostate cancer?

Date 30 September 2012
Event ESMO Congress 2012
Session Re-inventing the medical treatment of advanced prostate cancer
Topics Anti-Cancer Agents & Biologic Therapy
Prostate Cancer
Presenter Oliver Sartor
Authors O. Sartor
  • Department Of Medicine: Section Of Hematology & Medical Oncology And Department Of Urology, Tulane Cancer Center, 70112 - New Orleans/US

Abstract

The recent incremental advances in metastatic castrate-resistant prostate cancer (mCRPC) may one day translate into more meaningful change. Today mCRPC therapeutic choices are a sequential series of affairs with several either/or decisions. Optimal sequencing is unstudied and endless speculation abound as to which drug is best best for which patient. Combination therapies are in their infancy. In the past, the world of mCRPC was conveniently divided into the pre- and post-docetaxel space. That being said, the biologic basis for this was lacking and now we have new spaces such as the post-abiraterone/MDV3100 space that might in fact be more biologically meaningful. What do we do with patients progressing post-abiraterone or MDV3100? The data are sparse to date and so we gear up with new studies and read tea leaves in the interim. What is the role for cytotoxic chemotherapies today's mCRPC therapeutic armamentarium? The new hormonal therapies are now marching forward with provovative data in the “pre-chemotherapy” space. Novel immunotherapies have seized imaginations. The new world of truly active bone-targeted radiopharmaceuticals has arrived. Several facts seem clear. 1) the newer hormonal therapies are not effective for very long in mCRPC and after they fail, the progression rate can be very rapid. Exotic new molecular mechanisms of resistance are discovered with regularity; the CRPC cells are truly devious little Darwinian machines. 2) Today, death from prostate cancer is a foregone conclusion for mCRPC patient. So does this help us answer how we use cytotoxic chemotherapy today? Perhaps it si reasonable to point out that both docetaxel and cabazitaxel are clearly active agents and that some but not all patients will tolerate them well. Currently many men die from prostate cancer without having had the opportunity to benefit from known active agents. The best responses to chemotherapy, as with any agent, occur in patients with the best performance status. The concept that therapies of lesser toxicity should be administered first is appropriate but the concept that active therapies should be on the shelf when treating an incurable disease is not. Striving for patients to receive as many active therapies as feasible seems reasonable in an era when predicting therapeutic response is more art than science.

Disclosure

O. Sartor: Investigator and consultant for Algeta, Bayer, JNJ, Sanofi, and Dendreon. Consultant for Medivation and Astellas.