Metastatic castrate-resistant prostate cancer, dawn of a new age of management



I read with interest the Mini Review paper by Masson and Bahl [1] on metastatic castrate-resistant prostate cancer (mCRPC).

I fully agree with the authors' message that we are witnessing the ‘dawn of a new age management’; however, some new data concerning novel hormonal agents have been published since this paper was submitted, and I feel that an update is necessary.

With regard to patients with mCRPC after docetaxel failure:

  1. Abiraterone: the final analysis of the COU-AA-301 [2], published in October, confirms the value of this drug in patients who have undergone chemotherapy.
  2. Enzalutamide (formerly called MDV3100): the phase 3 AFFIRM trial has just been published in the September issue of the NEJM [3], demonstrating higher survival rates with enzalutamide in this setting.
  3. So now, we have two established oral agents in the treatment of post-docetaxel mCRPC, and the selection between these agents or cabazitaxel needs to be addressed.

With regard to chemotherapy-naïve patients:

  1. Abiraterone: data from the long-awaited COU-AA-302 are now available. This study was terminated early and unblinded as a result of an Independent Data Monitoring Committee decision. The results, presented at ASCO 2012 by Ryan et al. [4], revealed statistically better progression-free survival (PFS) and overall survival (OS) rates.
  2. Enzalutamide: the PREVAIL study is a phase III randomized, double-blind, placebo-controlled trial in chemo-naïve patients with mCRPC. The endpoints are OS and PFS. The study was closed to accrual in March 2012 and the results are awaited.
  3. The COU-AA-302 positive results with abiraterone (and the awaited PREVAIL trial data), along with the excellent safety profile of these two drugs, may signal a new paradigm shift in this era, leading us to investigate the appropriate sequencing in chemotherapy-naïve patients.