A STUDY PUBLISHED in December 2024 in JAMA Network Open found that a majority of men diagnosed with metastatic hormone-sensitive prostate cancer did not receive treatment intensification, the addition of supplemental drugs to traditional hormone therapy, despite guidelines that say intensification leads to better outcomes. The study found that 69.7% of patients did not receive first-line treatment intensification between 2018 and 2022.
For many years, giving a single testosterone-suppressing drug, known as androgen deprivation therapy (ADT), was the standard of care for men with this type of advanced prostate cancer. However, since 2017, guidelines have recommended including another hormone-blocking drug, an androgen receptor pathway inhibitor (ARPI). In some instances, chemotherapy is recommended as well.
The study was conducted between July 2018 and January 2022 and surveyed 107 U.S.-based physicians about their treatment for 617 patients with metastatic hormone-sensitive prostate cancer and the reasons for their treatment choices. The top reasons guiding care, both in cases where treatment intensification was used and where ADT was given alone, were concerns about side effects and adhering to national guidelines.
Neeraj Agarwal, lead investigator for the study and a medical oncologist at the University of Utah Huntsman Cancer Institute in Salt Lake City, says that despite doctors’ fears of treatment toxicity, data show the combination with ARPIs rarely leads to increased side effects.
“Pretty much every single trial that showed improved survival with these medications also showed one more thing, that quality of life, as reported by the patients, is not compromised,” he says.
While side effects are a concern with any drug, Christopher Wee, a medical oncologist with the Cleveland Clinic in Ohio who was not involved in the study, says it’s unlikely that adding the second drug for these patients will cause more side effects than using just one.
“In my experience, the androgen deprivation therapy that patients are also on tends to cause more noticeable side effects than the ARPI being used for treatment intensification,” Wee explains.
The side effects associated with the treatment combination tend to be manageable, Wee says, and the dose can be reduced or discontinued if side effects become too much for patients.
“Ultimately, any treatment decision is a risk/benefit calculation. The potential benefit of treatment intensification with an ARPI is pretty clear—improved overall survival,” he adds.
Awareness of Prostate Cancer Guidelines
The study also found that 61.5% of doctors reported following guidelines as a reason for their treatment choice. Agarwal says those who used ADT alone may have not been up to date on the latest guidelines and data on the benefits.
“They may not be aware of the latest data. They may not be in touch with the guidelines, and hence, they are not as proactive with using standard-of-care therapy,” he says.
A shift in awareness is already happening though, Agarwal says, and another study he is involved in will be presented this year in which patients were much more likely to undergo treatment intensification in 2023 and 2024 than in the years covered in this JAMA Network Open study.
The new research looked at a larger data set of patients and their doctors and found that more than 75% of patients were getting the recommended combination treatment over the past two years, he says.
Thomas Westbrook, a medical oncologist who specializes in prostate cancer at Rush MD Anderson Cancer Center in Chicago and was not involved in the study, says he uses treatment intensification for nearly all patients with metastatic prostate cancer.
“Most patients should have one of these agents [ARPIs] recommended because they have been shown to improve overall survival in the metastatic setting,” he explains.
There are some situations where treatment intensification may not be recommended, for instance, if the patient has a poor prognosis and adding another treatment will have little or no benefit. But for most patients, “there is more benefit than risk,” Westbrook says.
Even though more recent data suggests physicians are now recommending treatment intensification for most patients, Agarwal suggests patients facing a new diagnosis take some time to familiarize themselves with the latest research. He recommends consulting trusted resources like the Prostate Cancer Foundation.
“Take some time, so that when you go to the doctor’s office, you are already empowered with information and can bring up these treatment options,” he says.
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