WHEN ASKED which treatment to start with—docetaxel or enzalutamide, Dr. Sweeney said, “Patients fit for chemotherapy with high-volume disease can receive chemotherapy [docetaxel] and come back to these newer hormonal treatments or start with anyone of the hormonal options. Choosing among the newer hormonal agents if there is no contraindication any of them will be a Pepsi vs Coke type situation,” he continued.
“In this country, many patients and physicians have chemophobia,” stated Dr. Sweeney. “Chemotherapy still has a role in high volume disease if the patient is fit for docetaxel as well as in the castration resistant setting for all patients who are fit for chemotherapy. A patient with high volume disease could save money by giving chemotherapy for 6 cycles over 18 weeks and then adding the hormonal agent later when prostate-specific antigen rises. If the hormones are used upfront, about two thirds of patients will have 3 years of treatment with the expensive hormonal agents with their associated side effects. You can get chemotherapy out of the way by giving it first and this is most likely the time when the patient is fittest. We should therefore still offer docetaxel to chemofit patients with high volume disease as an option and ask the patient, what they want, realizing that many will most likely receive it for castration-resistant disease if not getting it upfront,” he suggested. “At this stage, adding enzalutamide to docetaxel does not seem to improve overall survival but does increase side effects and should be avoided for now until we have more evidence of clinical benefit.”
Dr. Agarwal had a different view. “I’ve seen few patients who are enthusiastic about chemotherapy, when we have oral pills that spare chemotherapy and steroids. This is an enormous advance. We have enzalutamide and apalutamide, which will allow patients to avoid chemotherapy and steroids (required with abiraterone). That’s my message.”
In a separate interview with The ASCO Post, Dr. Agarwal said: “There is no role or survival benefit to adding docetaxel to enzalutamide yet. We should avoid chemotherapy in patients who are receiving enzalutamide or vice versa. Based on current data, there is no role for combining chemotherapy with enzalutamide. The answer is simple: use one of them.” ■
