Optimizing the care of patients with advanced prostate cancer in the UK: current challenges and future opportunities

Study Type – Therapy (quality control) Level of Evidence 4 What's known on the subject? and What does the study add? Treatment options in the UK for men with metastatic castration-resistant prostate cancer (mCRPC) have been limited, and there is no standard approach, particularly in the second-line setting. The absence of a standard approach is further confounded by the differing definitions and terminologies still used in clinical practice to describe this group of patients (e.g. androgen-independent prostate cancer, hormone refractory prostate cancer, CRPC). With multiple new treatment options emerging, it will be critical to identify key considerations in our decision-making process and to establish an optimum, standardized approach to treatment so that new therapies can be assimilated into an mCRPC treatment algorithm and our routine clinical practice. Most UK oncologists consider patients with advanced, symptomatic prostate cancer as eligible for chemotherapy, although a poor performance status, significant co-morbid factors, advancing age, and the presence of asymptomatic disease with slowly rising prostate-specific antigen levels would prevent chemotherapy use. The decision to retreat with chemotherapy is largely driven by prior response to first-line chemotherapy. Many UK oncologists feel that UK clinical practice is likely to change over the next 5 years, with abiraterone acetate, MDV3100 and cabazitaxel likely to have the most positive impacts in the treatment of mCRPC. OBJECTIVES • To evaluate the current management of patients with advanced prostate cancer by UK oncologists. • To gain insights into the future role of emerging therapies. MATERIALS AND METHODS • A semi-structured questionnaire was issued by the British Uro-oncology Group to society members during a closed meeting in September 2010. • Emerging therapies evaluated were: abiraterone acetate, aflibercept, bevacizumab, cabazitaxel, custirsen, MDV3100, sipuleucel-T and zibotentan. RESULTS • Eighty of 98 (82%) surveys were completed. Responders had on average 189 new referrals, and treated 126 patients with advanced prostate cancer each year. • Chemotherapy was used by 86% of responders for patients with symptomatic metastatic castration-resistant prostate cancer (mCRPC), although poor performance status, advancing age and slowly rising prostate-specific antigen levels would prevent chemotherapy use. The decision to retreat with chemotherapy was largely driven by prior response to first-line chemotherapy, with docetaxel preferred for those responding. • Many (78%) felt that UK clinical practice was likely to change over the next 5 years, and that abiraterone acetate, MDV3100 and cabazitaxel would have the most positive impact. • Opinions regarding the future use of aflibercept and custirsen were mixed. • Few (≤3%) would use zibotentan or bevacizumab in the future based on recent negative phase III study results, or because of cost and complexity for sipuleucel-T. CONCLUSIONS • Although emerging therapies for mCRPC mean that the future is bright, guidelines are needed to ensure optimum use and sequencing of treatments. • Additional costs and anticipated workload associated with new agents will require careful consideration