Emerging Role of Chemotherapy and Hormonal Therapy in Advanced Prostate Cancer to Treat CRPC Daniel P. Petrylak , MD Professor of Medicine and Urology Director, Genitourinary DART Co-Director, Signal Transduction Program Smilow Cancer Center Yale University School of medicine
48
Embed
Emerging Role of Chemotherapy and Hormonal Therapy in Advanced Prostate Cancer Treat CRPCgpgu.org › wp-content › uploads › 2016 › 10 › 14-EMERGING-ROLE... · 2019-11-05 ·
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Emerging Role of
Chemotherapy and Hormonal
Therapy in Advanced
Prostate Cancer to Treat CRPC
Daniel P. Petrylak , MD
Professor of Medicine and UrologyDirector, Genitourinary DART
Co-Director, Signal Transduction ProgramSmilow Cancer Center
Yale University School of medicine
Sequencing CRPC therapy – 2010
Zoledronic acid with CRPC (metastatic disease)
Metastatic,
minimally
symptomatic
CRPC
Symptomatic
or poor-
prognosis
CRPC
Progression after
docetaxel
chemotherapy
Secondary
hormonal RxDocetaxel
MitoxantroneBest supportive care
not known 3 months not knownSurvival
benefit
Sequencing CRPC therapy – 2017
Abiraterone or Cabazitaxelacetate
Metastatic,
minimally
symptomatic
CRPC
Symptomatic
or poor-
prognosis
CRPC
Progression after
docetaxel
chemotherapy
Secondary
hormonal RxDocetaxel
not known 3 months not known
Sipuleucel-T Docetaxel
4 months 3 months 4 months 2.5 months
Denosumab or Zoledronic acid with CRPC (metastatic disease)
Survival
benefit
Survival
benefit
Mitoxantrone
Best supportive care 2010
2014
MDV3100 – 4.8 months
Rad 223 – 3.1 monthsMDV3100 – 2.2 months
Abiraterone – 5.2 months
Rad223 – 4.6 months
Classes of Agents
• Immunotherapeutic
– Sipuleucel T
• Hormonal
– MDV3100, Abiraterone , ?Docetaxel
• Cytotoxic
– Docetaxel, Cabazitaxel
• DNA Damage
– Rad 223
How do we sequence these
agents?
• Clinical Characteristics
– Symptomatic vs Asymptomatic
– Visceral vs Non Visceral
– Pre vs Post Docetaxel
• Biological Markers
– Androgen Receptor
– TRPMSS2-ERG
Development of Castrate Resistant Prostate Cancer
ALTERN.
SPLICING
ABERRANT
MODIFICATION
•GF, cytokines
•Src
Sumo
AC
P
COFACTOR
PERTURBATION
•CoAct gain
•CoR loss/dismissal
CoACT
INTRACRINE
ANDROGEN
SYNTHESIS
T
MUTATION•gain of function
AR
selective
pressure
Hormone Therapy
adaptation
CRPC
RESTORED AR ACTIVITY
(rising PSA)
RECURRENT TUMOR DEVELOPMENT
>30% CRPC
AR
DEREGULATION
•amplification
•overexpression
Penning and Knudsen. Trends Endocrinol Metab. 2010;21(5):315-24.
chemotherapy• Time to ECOG PS deterioration• Time to PSA progression
Saad F, et al. AUA 2013. Abstract 713
Statistically Significant Improvement Over Placebo in rPFS and all Secondary Endpoints
Patient reported outcomes favored AA + prednisone vs placebo + prednisone Full data to be reported
*Pre-specified alpha level 0.0035 Note: All secondary end points remain significant after adjusting for multiplicity testing
Outcome AA + PrednisoneMedian (months)
Placebo + PrednisoneMedian (months) HR (95% CI) P Value
rPFS 16.5 8.3 0.53 (0.45, 0.62) < 0.0001
OS 35.3 30.1 0.79 (0.66, 0.96) 0.0151 *
Time to opiate use
(cancer related pain)Not reached 23.7 0.71 (0.59, 0.85) 0.0002
Time to chemotherapy initiation
26.5 16.8 0.61 (0.51, 0.72) < 0.0001
Time to ECOG PS deterioration
12.3 10.9 0.83 (0.72, 0.94) 0.0052
Time to PSA progression 11.1 5.6 0.50 (0.43, 0.58) < 0.0001
Saad F, et al. AUA 2013. Abstract 713
Ryan et al. Final Overall Survival Analysis of COU-AA-302,a Randomized Phase 3 Study of Abiraterone Acetate in Metastatic
Castration-Resistant Prostate Cancer Patients Without Prior Chemotherapy
• Median follow-up of 49.2 mos
• Abiraterone treatment effect more pronounced when adjusting for 44% of prednisone patients who received subsequent abiraterone (HR = 0.74)
100
80
60
40
20
0
0
Ove
rall
Surv
ival
(%
)
9 21 30 48 6039
546542
525509
422401
296261
5942
00
AbirateronePrednisone
202148
Time to Death (Months)24123 36 45 54
538534
453438
359322
189132
1510
HR (95% CI): 0.81 (0.70-0.93)
p Value: 0.0033
Prednisone, 30.3 mos
Abiraterone, 34.7 mos
6 15 18 27 33 42 51 57
01
11884
218176
504493
483466
394363
330292
273227
235201
Enzalutamide• Oral drug rationally
designed to target AR signaling, impacting multiple steps in AR signaling pathway
• No demonstrated agonist effects in pre-clinical models
Tran C et al. Science 2009;324:787-790.
T
T
AR
Nucleus
EnzalutamideInhibits Binding of Androgens to AR
Inhibits Nuclear Translocation of AR
Inhibits AssociationOf AR with DNA
Tumor Death
AR
Cytoplasm
X
X
X
Enzalutamide Prolonged Survival, Reducing Risk of Death
Scher HI, et al. N Engl J Med. 2013; 367:1187-1197
Median OS Δ: 4.8 months37% reduction in risk of death
Enzalutamide Placebo
MedianOverall Survival (months)
18.4 13.6
Hazard ratio 0.63 95% CI 0.53, 0.75P value < 0.001
1°end point: OS and PFS
Enzalutamide 160mg QD
Placebo QD
PREVAIL Phase III Trial of Enzalutamide in Asymptomatic or Mildly Symptomatic
mCRPC Pre Chemotherapy
RANDOMIZE
1:1
mCRPCasymptomatic or
mildly symptomatic patients < 4 BPI
(n=1,680)Fully Accrued
A safety and efficacy study of oral MDV3100 in chemotherapy-naive patients with progressive metastatic prostate cancer (PREVAIL)(NCT01212991). Available at www.clinicaltrials.gov. Accessed August 21, 2013.
PREVAIL Phase III Trial of Enzalutamide in Asymptomatic or Mildly Symptomatic mCRPC
Pre Chemotherapy Prelimianry Results
• Overall Survival 30% reduction in the risk of death