Table of Contents  
Year : 2014  |  Volume : 16  |  Issue : 3  |  Page : 331-333

The metastatic castration-resistant prostate cancer treatment paradigm: more choices, more questions

1 Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA 98109, USA
2 Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA

Date of Web Publication08-Apr-2014

Correspondence Address:
Evan Y Yu
Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA 98109
William K Oh
Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1008-682X.127813

Rights and Permissions

How to cite this article:
Yu EY, Oh WK. The metastatic castration-resistant prostate cancer treatment paradigm: more choices, more questions. Asian J Androl 2014;16:331-3

How to cite this URL:
Yu EY, Oh WK. The metastatic castration-resistant prostate cancer treatment paradigm: more choices, more questions. Asian J Androl [serial online] 2014 [cited 2021 Jul 26];16:331-3. Available from: - DOI: 10.4103/1008-682X.127813

The world of prostate cancer has dramatically changed in the last few years. The original paradigm that metastatic castration-resistant prostate cancer (mCRPC) is untreatable is clearly wrong.

In 2004, docetaxel demonstrated a modest, yet meaningful survival and pain palliative benefit. [1],[2] The field then went through a long approval "drought," where a number of drug combinations with docetaxel were not found to add benefit; [3],[4],[5],[6],[7] no new therapeutic agents were approved again until 2010. Since then, however, we have seen the approval of sipuleucel-T, [8] cabazitaxel, [9] abiraterone, [10],[11] enzalutamide [12] and radium-223 [13] broaden the menu of agents that prolong overall survival in mCRPC. In addition, denosumab was found to be superior in time to the skeletal-related event (SRE) over zoledronic acid for those with castration-resistant bone metastases. [14]

What is most remarkable is that each new agent listed above has a distinct mechanism of action. Although each is moderately effective, none of these agents offer a cure and the biologic and clinical data to explain mechanisms of drug resistance remains scanty at best. As a result, the field must now rely on practical considerations, with much data extrapolation, to fuel logical utilization and sequencing of these therapies in hopes of achieving optimal patient outcomes.

In this special issue, these new agents will be discussed thoroughly. This includes review of biologic mechanism of action, clinical efficacy and safety data, biomarkers and opinions on pragmatic use and combinations for future exploration. Although, the topics may be drug-focused, there is the inclusion of broad discussion on entire fields of therapy with historical and pre-clinical perspective. This includes a review of traditional chemotherapy, immunotherapy, hormonal agents, bone-specific therapy and other pathways currently under exploration with therapeutic agents in clinical testing.

Although, these articles are extremely comprehensive in nature, we must recognize that more therapeutic options naturally lead to more questions of how best to optimize treatment outcomes. Below, we propose some of the most pressing questions facing clinicians in the field of mCRPC. This discussion is accompanied with the caveat that our successes have led to more questions than answers.

  When Should Sipuleucel-T Be Administered? Top

Sipuleucel-T administration comes with many challenges such as lack of prostate-specific antigen (PSA) decline, lack of improvement in progression endpoints and no clear predictive or response biomarkers. Singh and Gulley [15] discuss data from the IMPACT trial that shows that those with the lowest PSA quartile levels at baseline derive the greatest benefit from sipuleucel-T compared to placebo. [16] Although retrospective, these data support the concept that earlier introduction of immunotherapy in patients with a lower disease burden may be optimal. The authors also discuss emerging blood- and tissue-based immune markers that offer pharmacodynamic evidence of in vivo immune response, many with survival correlates. [17] With increasing evidence supporting the use of immunotherapy in cancers in general and specifically in prostate cancer, it is important to recognize the difference in antineoplastic kinetics, [18] shed traditional methods of measuring antitumor treatment response and instead, seek new endpoints that capture meaningful clinical benefit. This will require persistent focus on discovery of predictive biomarkers that can be readily accessible in clinic.

  Abiraterone, Enzalutamide and Beyond. How Should we be Sequencing New Androgen Signaling Inhibitors? Top

Potent agents that target the androgen/androgen receptor (AR) axis are being utilized earlier in the mCRPC treatment paradigm. Stein [19] provides a refined discussion on abiraterone and other androgen synthesis inhibitors. With the recent PREVAIL data, [20] enzalutamide will likely receive regulatory approval in the pre-chemotherapy space in the near future. Yet, there is scant data surrounding sequencing of abiraterone and enzalutamide. Multiple retrospective reports describe the blunted response to the second of these two agents when given in sequence. [21],[22],[23],[24],[25],[26],[27],[28] Yet, a substantial proportion of patients still respond to the second agent, emphasizing a biologic principal that mechanisms of resistance to androgen synthesis inhibitors and potent AR inhibitors may be distinct in a subset of patients. For the time being, practical factors such as patient comorbidities and issues surrounding steroid use may determine selection and sequencing of abiraterone and enzalutamide. [29] Identifying mechanisms of resistance to these agents should help us to optimize sequencing of drugs and allow biologically rational combinations to be tested.

  When is the Optimal Timing for Chemotherapy? Top

With the introduction of potent novel hormonal therapies with favorable toxicity profiles, it is not surprising that traditional chemotherapy is being pushed further back in the treatment paradigm. However, there are ongoing trials studying optimal use of docetaxel, cabazitaxel and novel combinations. [30] In addition, we eagerly await the upcoming presentation of data from ECOG 3805 which has described in the press release format that adding 6 cycles of docetaxel chemotherapy to standard androgen deprivation therapy (ADT) at the time of new metastatic prostate cancer offers a significant survival advantage ( ). There will be much to consider and scrutinize, including side-effect profiles, quality of life measures and degree of efficacy. Overall, this prompts the question: when is the best time to initiate chemotherapy? Will positive survival data from a hormone-sensitive trial lead clinicians to introduce chemotherapy at the earliest point possible or will chemotherapeutic agents continue to be pushed later due to issues of tolerability and quality of life?

  Radium-223 Offers Survival Benefit in Bone MCRPC, Both in The Pre- and Post-Chemotherapy Setting. When Should We Use It? Top

Radium-223 is the newest agent to be added to the mCRPC treatment menu, as it was recently approved for patients with symptomatic bone metastasis who lack visceral metastasis. This alpha-emitting radiopharmaceutical is attractive since it seems to carry low toxicity while offering overall survival, symptomatic skeletal event (SSE) and pain palliative benefits. [31] Yet there are many unanswered questions still in the early days of this agent. For instance, why does PSA inconsistently correlate with outcomes? What should we expect with imaging in patients undergoing radium-223 and can it help us tailor therapy?

However, the most practical issue for clinicians is whether there is an optimal sequence to use radium-223 with other agents, including chemotherapy? Patients who have received prior chemotherapy or radiation and those with more bone metastases are at greatest risk of myelosuppression after administration of radium-223. [32] Therefore, patients that have been more heavily pre-treated may be more limited in ability to receive and complete the full 6 cycles of radium-223. Meanwhile, there are fewer restrictions and greater flexibility for clinicians to decide on chemotherapy usage and dosing. This leads to the question of whether radium-223 is best administered early?

  Are Bone-Targeted Therapies Still as Important in This Disease as They Once Were? Top

Bone morbidity remains a major complication that all patients face and utilization of bone-targeted therapy with either denosumab or zoledronic acid effectively decrease skeletal events. [14],[33] However, special attention needs to be paid to this topic in prostate cancer. One important point is that all the positive skeletal event prevention trials were performed in patients with castration-resistant disease. [34] In the metastatic hormone-sensitive setting, early introduction of zoledronic acid did not offer a SRE benefit. [35] A natural extrapolation is that ADT is highly efficacious and patients undergoing effective therapy are likely have less skeletal morbidity, perhaps negating the need for bone supportive therapy. In the modern era, highly efficacious agents such as abiraterone, enzalutamide and radium-223 have all demonstrated survival and SRE benefit. [12],[13],[36] Therefore, we are left with practical considerations as to whether anti SRE-only therapy should continue to be extensively utilized or reserved for special situations.

  What New Targets and Pathways are Being Addressed in Ongoing and Future Clinical Trials? Top

This is the broadest question, so we have selected a few promising targets and pathways for this special issue. The PI3K-AKT-mTOR axis is important in many cancers but has gained much attention in prostate cancer recently. [37] The concept of reciprocal activation between the PI3K-AKT-mTOR and AR signaling pathways have led to enthusiasm to combine inhibitors of this pathway with novel AR axis drugs. [38] Similarly, Zhang discusses rationale for poly (ADP-ribose) polymerase inhibition in combination with ADT, chemotherapy and radiation therapy in prostate cancer. [39] Inhibiting clusterin, an anti-apoptotic protein through direct inhibition of Bax activation, [40] may help alleviate docetaxel resistance; the field eagerly awaits phase 3 results of a randomized, phase 3 combination trial of docetaxel with custirsen, an antisense to clusterin. [41] Bilusic and Wong review the "lessons learned" from failed anti-angiogenic agents in prostate cancer such as bevacizumab, sorafenib, sunitinib, aflibercept, thalidomide and lenolidamide. [42] Importantly, the endpoints utilized in most of those trials may not have been ideal to capture efficacy of an anti-angiogenic agent against prostate cancer. However, we still await the results from phase 3 trials with cabozantinib and tasquinimod in mCRPC.

In summary, the therapeutic advancements for mCRPC have created multiple new challenges moving forward. The most obvious change is that placebo-controlled trials to demonstrate overall survival will likely not happen moving forward. Thus, the regulatory options for developing a new drug will either be in combination with an existing agent, for an indication created with a new disease state, or perhaps direct comparison with one of the new highly efficacious agents. Another consideration is to move earlier and an example of this is with ARN-509, a pure AR antagonist being tested in the SPARTAN trial (NCT01946204) in the M0 CRPC, or non-mCRPC, disease state. The obvious challenge with moving earlier is finding a meaningful endpoint that not only has clinical impact but also meets regulatory hurdles. Otherwise, enormous trials with extremely long follow-up would test the field in terms of the patient and financial resources. Regardless, greater efforts must be made to understand tumor biology and mechanisms of drug sensitivity and resistance. We challenge the field to develop predictive and response biomarkers while maturing efforts to biologically characterize individual patient tumors through circulating tumor cells, metastatic biopsies, imaging and other creative means.

  References Top

1.Petrylak DP, Tangen CM, Hussain MH, Lara PN Jr, Jones JA, et al. Docetaxel and estramustine compared with mitoxantrone and prednisone for advanced refractory prostate cancer. N Engl J Med 2004; 351: 1513-20.  Back to cited text no. 1
2.Tannock IF, de Wit R, Berry WR, Horti J, Pluzanska A, et al. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. N Engl J Med 2004; 351: 1502-12.  Back to cited text no. 2
3.Quinn DI, Tangen CM, Hussain M, Lara PN Jr, Goldkorn A, et al. Docetaxel and atrasentan versus docetaxel and placebo for men with advanced castration-resistant prostate cancer (SWOG S0421): a randomised phase 3 trial. Lancet Oncol 2013; 14: 893-900.  Back to cited text no. 3
4.Araujo JC, Trudel GC, Saad F, Armstrong AJ, Yu EY, et al. Docetaxel and dasatinib or placebo in men with metastatic castration-resistant prostate cancer (READY): a randomised, double-blind phase 3 trial. Lancet Oncol 2013; 14: 1307-16.  Back to cited text no. 4
5.Fizazi KS, Higano CS, Nelson JB, Gleave M, Miller K, et al. Phase III, randomized, placebo-controlled study of docetaxel in combination with zibotentan in patients with metastatic castration-resistant prostate cancer. J Clin Oncol 2013; 31: 1740-7.  Back to cited text no. 5
6.Kelly WK, Halabi S, Carducci M, George D, Mahoney JF, et al. Randomized, double-blind, placebo-controlled phase III trial comparing docetaxel and prednisone with or without bevacizumab in men with metastatic castration-resistant prostate cancer: CALGB 90401. J Clin Oncol 2012; 30: 1534-40.  Back to cited text no. 6
7.Tannock IF, Fizazi K, Ivanov S, Karlsson CT, Fléchon A, et al. Aflibercept versus placebo in combination with docetaxel and prednisone for treatment of men with metastatic castration-resistant prostate cancer (VENICE): a phase 3, double-blind randomised trial. Lancet Oncol 2013; 14: 760-8.  Back to cited text no. 7
8.Kantoff PW, Higano CS, Shore ND, Berger ER, Small EJ, et al. Sipuleucel-T immunotherapy for castration-resistant prostate cancer. N Engl J Med 2010; 363: 411-22.  Back to cited text no. 8 Bono JS, Oudard S, Ozguroglu M, Hansen S, Machiels JP, et al. Prednisone plus cabazitaxel or mitoxantrone for metastatic castration-resistant prostate cancer progressing after docetaxel treatment: a randomised open-label trial. Lancet 2010; 376: 1147-54.  Back to cited text no. 9 Bono JS, Logothetis CJ, Molina A, Fizazi K, North S, et al. Abiraterone and increased survival in metastatic prostate cancer. N Engl J Med 2011; 364: 1995-2005.  Back to cited text no. 10
11.Ryan CJ, Smith MR, de Bono JS, Molina A, Logothetis CJ, et al. Abiraterone in metastatic prostate cancer without previous chemotherapy. N Engl J Med 2013; 368: 138-48.  Back to cited text no. 11
12.Scher HI, Fizazi K, Saad F, Taplin ME, Sternberg CN, et al. Increased survival with enzalutamide in prostate cancer after chemotherapy. N Engl J Med 2012; 367: 1187-97.  Back to cited text no. 12
13.Parker C, Nilsson S, Heinrich D, Helle SI, O'Sullivan JM, et al. Alpha emitter radium-223 and survival in metastatic prostate cancer. N Engl J Med 2013; 369: 213-23.  Back to cited text no. 13
14.Fizazi K, Carducci M, Smith M, Damião R, Brown J, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet 2011; 377: 813-22.  Back to cited text no. 14
15.Singh BH, Gulley JL. Immunotherapy and therapeutic vaccines in prostate cancer: an update on current strategies and clinical implications. Asian J Androl 2014; 16: 364-71.  Back to cited text no. 15
16.Schellhammer PF, Chodak G, Whitmore JB, Sims R, Frohlich MW, et al. Lower baseline prostate-specific antigen is associated with a greater overall survival benefit from sipuleucel-T in the Immunotherapy for Prostate Adenocarcinoma Treatment (IMPACT) trial. Urology 2013; 81: 1297-302.  Back to cited text no. 16
17.Sheikh NA, Petrylak D, Kantoff PW, Dela Rosa C, Stewart FP, et al. Sipuleucel-T immune parameters correlate with survival: an analysis of the randomized phase 3 clinical trials in men with castration-resistant prostate cancer. Cancer Immunol Immunother 2013; 62: 137-47.  Back to cited text no. 17
18.Madan RA, Gulley JL, Kantoff PW. Demystifying immunotherapy in prostate cancer: understanding current and future treatment strategies. Cancer J 2013; 19: 50-8.  Back to cited text no. 18
19.Stein MN, Bershadskiy A, Skoloff A, Singer EA. Androgen synthesis inhibitors in the treatment of castration-resistant prostate cancer. Asian J Androl 2014; 16: 387-400.  Back to cited text no. 19
20.Beer TM, Armstrong AJ, Sternberg CN, Higano CS, Iversen P, et al. Enzalutamide in med with chemotherapy-naive metastatic prostate cancer: results of phase III PREVAIL study. J Clin Oncol 2014; 32 suppl 4: abstr LBA1.  Back to cited text no. 20
21.Loriot Y, Bianchini D, Ileana E, Sandhu S, Patrikidou A, et al. Antitumour activity of abiraterone acetate against metastatic castration-resistant prostate cancer progressing after docetaxel and enzalutamide (MDV3100). Ann Oncol 2013; 24: 1807-12.  Back to cited text no. 21
22.Noonan KL, North S, Bitting RL, Armstrong AJ, Ellard SL, et al. Clinical activity of abiraterone acetate in patients with metastatic castration-resistant prostate cancer progressing after enzalutamide. Ann Oncol 2013; 24: 1802-7.  Back to cited text no. 22
23.Schrader AJ, Boegemann M, Ohlmann CH, Schnoeller TJ, Krabbe LM, et al. Enzalutamide in castration-resistant prostate cancer patients progressing after docetaxel and abiraterone. Eur Urol 2014; 65: 30-6.  Back to cited text no. 23
24.Bianchini D, Lorente D, Rodriguez-Vida A, Omlin A, Pezaro C, et al. Antitumour activity of enzalutamide (MDV3100) in patients with metastatic castration-resistant prostate cancer (CRPC) pre-treated with docetaxel and abiraterone. Eur J Cancer 2014; 50: 78-84.  Back to cited text no. 24
25.Thomsen FB, Røder MA, Rathenborg P, Brasso K, Borre M, et al. Enzalutamide treatment in patients with metastatic castration-resistant prostate cancer progressing after chemotherapy and abiraterone acetate. Scand J Urol 2013 Nov 21. [Epub ahead of print].  Back to cited text no. 25
26.Badrising S, van der Noort V, van Oort IM, van den Berg HP, Los M, et al. Clinical activity and tolerability of enzalutamide (MDV3100) in patients with metastatic, castration-resistant prostate cancer who progress after docetaxel and abiraterone treatment. Cancer 2013; 120: 968-75.  Back to cited text no. 26
27.Schmid SC, Geith A, Böker A, Tauber R, Seitz AK, et al. Enzalutamide after docetaxel and abiraterone therapy in metastatic castration-resistant prostate cancer. Adv Ther 2014; 31: 234-41.  Back to cited text no. 27
28.Cheng HH, Nadal R, Gulati R, Azad A, Twardowski P, et al. The effect of prior abiraterone use on the activity of enzalutamide in men with metastatic castration-resistant prostate cancer. J Clin Oncol 2014; 32 suppl 4: abstr 18.  Back to cited text no. 28
29.Montgomery RB, Cheng HH, Drechsler J, Mostaghel EA. Glucocorticoids and prostate cancer treatment: friend of foe? Asian J Androl 2014; 16: 354-8.  Back to cited text no. 29
30.Schweizer MT, Antonarakis ES. Chemotherapy and its evolving role in the management of advanced prostate cancer. Asian J Androl 2014; 16: 334-40.  Back to cited text no. 30
31.Vuong W, Sartor AO, Pal SK. Radium-223 in metastatic castration resistant prostate cancer. Asian J Androl 2014; 16: 348-53.  Back to cited text no. 31
32.Parker C, Garcia-Vargas JE, O'Bryan-Tear CG, Fang F, Vogelzang NJ. Hematologic safety of Ra-223 dichloride in castration-resistant prostate cancer patients with bone metastases from the phase III ALSYMPCA trial. J Clin Oncol 2013; 30 suppl: abstr 5060.  Back to cited text no. 32
33.Saad F, Gleason DM, Murray R, Tchekmedyian S, Venner P, et al. A randomized, placebo-controlled trial of zoledronic acid in patients with hormone-refractory metastatic prostate carcinoma. J Natl Cancer Inst 2002; 94: 1458-68.  Back to cited text no. 33
34.Saylor PJ. Bone targeted therapies for the prevention of skeletal morbidity in men with prostate cancer. Asian J Androl 2014; 16: 341-7.  Back to cited text no. 34
35.Smith MR, Halabi S, Ryan CJ, Hussain A, Vogelzang N, et al. Randomized Controlled Trial of Early Zoledronic Acid in Men With Castration-Sensitive Prostate Cancer and Bone Metastases: Results of CALGB 90202 (Alliance). J Clin Oncol. 2014 Mar 3. doi: 10.1200/JCO.2013.53.8900. [Epub ahead of print].  Back to cited text no. 35
36.Logothetis CJ, Basch E, Molina A, Fizazi K, North SA, et al. Effect of abiraterone acetate and prednisone compared with placebo and prednisone on pain control and skeletal-related events in patients with metastatic castration-resistant prostate cancer: exploratory analysis of data from the COU-AA-301 randomised trial. Lancet Oncol 2012; 13: 1210-7.  Back to cited text no. 36
37.Edlind MP, Hsieh AC. PI3K-AKT-mTOR signaling in prostate cancer progression and androgen deprivation therapy resistance. Asian J Androl 2014; 16: 378-86.  Back to cited text no. 37
38.Carver BS, Chapinski C, Wongvipat J, Hieronymus H, Chen Y, et al. Reciprocal feedback regulation of PI3K and androgen receptor signaling in PTEN-deficient prostate cancer. Cancer Cell 2011; 19: 575-86.  Back to cited text no. 38
39.Zhang J. Poly (ADP-ribose) polymerase inhibitor: an evolving paradigm in the treatment of prostate cancer. Asian J Androl 2014; 16: 401-6.  Back to cited text no. 39
40.Zhang H, Kim JK, Edwards CA, Xu Z, Taichman R, et al. Clusterin inhibits apoptosis by interacting with activated Bax. Nat Cell Biol 2005; 7: 909-15.  Back to cited text no. 40
41.Albany C, Hahn NM. Heat shock proteins and apoptosis as therapeutic targets in prostate cancer. Asian J Androl 2014; 16: 359-63.  Back to cited text no. 41
42.Bilusic M, Wong YN. Anti-angiogenesis in prostate cancer: knocked down but not out. Asian J Androl 2014; 16: 372-7.  Back to cited text no. 42


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
When Should Sipu...
Abiraterone, Enz...
When is the Opti...
Radium-223 Offer...
Are Bone-Targete...
What New Targets...

 Article Access Statistics
    PDF Downloaded618    
    Comments [Add]    

Recommend this journal