DR SARTOR: First of all, I don’t think we know. And anybody who takes a stance that they do know, I’d love to hear their data, because I certainly haven’t seen it. But that being said, there are certain things, I think, that might push you a little bit one way or another. If you’ve got a diabetic, for instance, you may want to avoid prednisone for the corticoid issue. In a patient with a past history of seizures or dural mets or something like that, you may want to move away from enzalutamide.
But I think we have very little data right now in order to make a decision. I want to hear what others think.
DR LOVE: Before we get to the others, what do you want to do? What would you like to do? A coin flip?
DR SARTOR: Coin flip.
DR BEER: I think I would, given no data, go with enzalutamide first.
DR PETRYLAK: Again, given no data, especially since you’re trying to sequence some of these drugs, if you believe that corticosteroids may have an abrogatory effect on sipuleucel-T, I would tend to go with enzalutamide first rather than abiraterone and prednisone. But again, there are no data. There are actually trials that are addressing that issue.
DR SMITH: I have temporary respite from this question. I’d say we do have the COUGAR 302 data. So I think while we have that data and the longer personal experience with abiraterone acetate, I would prefer to use that first for now in the prechemotherapy setting. It’s a very transient answer, and we’ll await the results of the PREVAIL trial.
My expectation is that that study will be remarkably similar to the COUGAR 302 trial, although there is a possibility that it would provide some evidence of superiority with all the usual limitations of comparing between trials.
DR LOVE: So that’s a prechemo trial.
DR SMITH: So yes, which is a very similar setting to the COUGAR 302 trial. So we will have another opportunity to compare the 2 drugs.
DR LOVE: Mario? Enzalutamide or abiraterone first?
DR EISENBERGER: Enzalutamide. I think clearly it’s easier to use. It’s less toxic. No need for steroids. I think that patients, as they have less disease, they’ll likely benefit from this longer. So the longer use of corticosteroids may become an issue. And I think it’s also a simpler drug, so that’s what I would do. But I would stress again that there’s a great opportunity for clinical trials in combined androgen blockades, combined androgen signaling compounds. And I think that that is what we should stress here, especially since there’s no consensus. And there may be a consensus, which is driven by the comments that we just heard here.
DR LOVE: I’ve got to say that it’s been kind of disappointing in breast cancer, combined endocrine therapy. It’s been tried a lot, and a little bit of evidence — not too much. Susan, enzalutamide or abiraterone?
DR SLOVIN: I would do enzalutamide with 1 caveat. If somebody has already been on bicalutamide and leuprolide, their PSA is going up very rapidly, very high-grade disease, I might want to change the category of drugs and go to a completely different class, which would be abiraterone.
DR DREICER: So, with all the caveats, enzalutamide. And I’d also remind us that it ain’t cheap anymore. So this is getting to be an economic issue as well. And enzalutamide pricing is higher than abiraterone pricing, and we’re going to have issues here.
DR OH: I would probably say enzalutamide. And the reason, of course, is that in situations that we’ve been in, like before, when we have 2 drugs that appear to be equal, even though they haven’t been compared head to head, we usually vote for the one that has less toxicity. And I think that enzalutamide is more favorable.