DR SMITH: So I’d be most enthusiastic about abiraterone acetate or enzalutamide in that setting.
DR LOVE: Both asymptomatic and symptomatic?
DR SMITH: The asymptomatic patient for sure. Symptomatic, it would not preclude me from using it. If the patient had rapid progression, short response to ADT, loss of current constitutional symptoms, I would have more enthusiasm for going right to docetaxel.
DR PETRYLAK: Asymptomatic, I would consider sipuleucel-T as front-line therapy. Symptomatic, again, as Matt said, depending upon the rapidity of progression, if somebody’s rapidly progressing, short response to hormones, I would go to chemotherapy first. If they’ve had a more prolonged response to hormone therapy, I would at this point go with abiraterone.
DR LOVE: And in the asymptomatic patient you’d put on sip-T, what would be next?
DR PETRYLAK: I would prefer enzalutamide because of the steroid issue, but abiraterone right now would be the treatment of choice.
DR SARTOR: I think I’m Dan’s partner. Sipuleucel-T for the asymptomatic patient. For the symptomatic patient, rapid progressor, I’m thinking about docetaxel. For the other patients I might be thinking more about the abiraterone/prednisone.
DR LOVE: And in the patient second line, who’s asymptomatic, after sip-T?
DR SARTOR: Would have no hesitancy to use the abiraterone acetate in that setting.
DR OH: I’d start with sip-T in the asymptomatic patient. Enzalutamide, I think that’d be another consideration. In the symptomatic patient, again, I think it depends on how symptomatic, but abiraterone, if they haven’t already received it, or chemotherapy if they’re rapidly progressing.
DR LOVE: And the asymptomatic sip-T first, what’s second?
DR OH: Enzalutamide.
DR DREICER: Asymptomatic would be sip-T followed by either enzalutamide or abi. The symptomatic patient, one of those two unless visceral crisis disease, and then I would use docetaxel.
DR SLOVIN: Asymptomatic, either enzalutamide or abiraterone. Symptomatic, again, depending on the PSA doubling time, symptoms, I would either go to chemotherapy or abiraterone.
DR EISENBERGER: For asymptomatic patients, I would offer a secondary hormonal therapy with either abiraterone, enzalutamide or, if not possible for financial reasons, ketoconazole. I would consider sip-T as an option. I don’t actively offer that, but if a patient wished to have it, I don’t have any argument against it. The trials with secondary hormonal therapies with current compounds in the prechemotherapy setting were for patients with mildly symptomatic disease or asymptomatic disease, so there’s not a lot of data. But based on what we know with ketoconazole, I see no reason why patients wouldn’t respond to abiraterone, so I certainly would offer that. I would like to see a little more data on PREVAIL, but I suspect that the data will be just like abiraterone, will show an active compound in that setting for symptomatic patients and asymptomatic patients. There is a subset of patients who progress very rapidly on hormonal therapy. And these patients, I may offer them a docetaxel-based regimen. In all these 3 scenarios, I still think it’s reasonable to discuss clinical trials.
DR SLOVIN: I would say that most of it is driven by the patient’s comfort zone, as well as my own. So if this is a person whose PSA is doubling and tripling in a very short period of time, whether or not they’re symptomatic or asymptomatic, I would pull the trigger. Most patients just don’t like to sit between therapies. So I end up sometimes ordering scans a little bit more frequently than I would prefer, because it gives the patient an idea that it’s more comfortable. They have nothing that’s changed progressively in their disease.
The only other thing that really will drive me toward doing something about their disease is if they say to me, “Doc, I can’t get up in the morning. I’m just not eating. I’ve lost 5 pounds in the last month.” I will pull the trigger.
DR LOVE: Mario, chemo, docetaxel, in a patient who’s asymptomatic?
DR EISENBERGER: I don’t see any problem in waiting, if patients are totally asymptomatic and primarily presenting with a rising PSA as evidence of disease activity. If I see very rapid radiological progression, I probably will try to persuade the patient a little more. But I do discuss with all patients what the role of chemotherapy is, what the side effects are and have them participate in the decision.