How AR Therapy Has Changed the nmCRPC & mCSPC Treatment Landscape

Neeraj Agarwal, MD:How is the approval of apalutamide, enzalutamide, and soon-to-be-approved darolutamide going to change the treatment paradigm for our patients? We did not have anything to treat our patients with in this setting. We just waited for them to have metastasis. Now we have these 3 drugs. Not surprisingly, apalutamide and enzalutamide are already a part of NCCN [National Comprehensive Cancer Network] and AUA [American Urological Association] guidelines, and they’re already approved. The same will happen with darolutamide. As soon as it is approved, we will see darolutamide become a part of these guidelines. So our patients have 3 exciting drugs that have a minimal impact on quality of life. In fact, quality of life improved on these trials when patients were treated with these agents. So we’ll have these options available in our clinic.

We have 2 new drugs, which will be added to the treatment arsenal of castration-sensitive metastatic prostate cancer. This includes enzalutamide and apalutamide—direct, novel, specific androgen receptor inhibitors. How is this going to change the current treatment paradigm? Let’s take a step back and see what we are using right now.

The 2 classes of drugs that are currently approved for our patients with castration-sensitive metastatic prostate cancer include, No. 1, docetaxel chemotherapy. Most of my patients have no enthusiasm to receive chemotherapy. Chemotherapy has its own adverse effects and complications. We are also all aware of the use of concomitant steroids, and there can be a meaningful impact on one’s quality of life.

The second option is abiraterone, or Zytiga, which requires concomitant steroids for many months to many years. These are the 2 current options we have. And now comes enzalutamide and apalutamide. These are drugs that do not require concomitant steroids, which are not associated with complications of chemotherapy. I think the approval of apalutamide is going to be a very welcome option for the majority of my patients—who are not interested in chemotherapy, who are not interested in long-term steroids, and who want to preserve their quality of life—as we saw in the TITAN trial.

With the availability of apalutamide, we have this option of an oral pill. The patient can just take the bottle of the oral pill provided by their doctor and use those pills by themselves without having to worry about so many adverse effects.

Transcript edited for clarity.