Sequencing medical therapy in prostate cancer: not as easy as 1-2-3.

In their article in this issue of ONCOLOGY, Drs. Hurwitz and Petrylak have very effectively reviewed recent progress in the treatment of advanced prostate cancer.[1] Enhanced understanding of the biologic drivers of disease progression and treatment resistance has led to prolific research, new therapeutic discoveries, and the timely approval of new agents. The authors note that currently the proper sequencing of these therapies may depend on consideration of the side effects of therapy, as no definitive comparison of efficacy exists. Choosing a treatment involves assessment of both the biology of the disease (ie, sites of metastasis, rate of disease progression, and response to previous therapy) and the characteristics of the patient (ie, physiologic age, residual effects of previous therapy, comorbidities, and goals of treatment). In considering these factors one must remember the broad demographic features of prostate cancer patients, including that the majority of prostate cancer patients are over 65 years old and that the unique needs of an older cancer population must be a priority as these new therapies are integrated into routine care. Another key factor in determining the appropriate sequencing of these agents is the acknowledgement that we are treating a moving target. With the early, prechemotherapy use of abiraterone acetate, and the likely use of enzalutamide in the future, the biologic behavior of the prostate cancer that emerges from “complete” androgen blockade may be different from that of the historically defined and studied entity of castrate-resistant prostate cancer (CRPC).