PracticeUpdate Oncology Best of 2018

EXPERT OPINION 23

Evidence-Based Chemotherapy for Oligometastatic Prostate Cancer

to anthracycline cardiotoxicity, but now we will see more and more related to trastuzumab cardiotoxicity. The trials before there were two major trials and they were negative, so now we’re looking is there something positive? Dr. Caudle: Finally, how do you feel that the future of management of chemotherapy-induced cardiotoxicity will change? What do you think about that? Dr. Herrmann: There are really active efforts of all the major car- diology societies, but also the oncology societies who have come to the realization that this is an issue particularly as it pertains to those aspects I’ve mentioned. If it doesn’t allow the oncologist to complete chemotherapy, that’s really an issue. And so, we will see more formulated and, hopefully with the trials being presented, more and more guideline type style of recommendations. I have to say that, for the most part, what we have are consensus papers where a group of experts got together and just summarized the evidence. But what we really need, and what is hopefully to come in the next few years, are more evidence-based guidelines. So, I think that’s where this is going. these are patients who’ve received, many of them, five or more lines of therapy. So, this is a very exciting drug that I’m looking forward to seeing more data on. Dr. Sandoval Leon: And currently what is the role of immunotherapy for these patients? Dr. Hurvitz: Not outside of a clinical trial. Dr. Sandoval Leon: Have you seen any promising? Dr. Hurvitz: I think immune therapy is promising, but it’s promising for the minority. We’re seeing objective response rates in fewer than 20% of patients in general, although some of the responses are quite durable. So, for some patients it’s a home run, but we need to define who those patients are. Dr. Sandoval Leon: What do you think will be the future in treating these patients with HER2-positive cancer? Probably the first- and second-line will remain the same and then we’ll get more options for third-line and beyond? Dr. Hurvitz: I don’t know. DS-8201 may bump out, may go head to head against T-DM1 or the frontline therapy if the results remain this exciting. It could be the drug that changes the paradigm in the way we treat. I think that, however, most of the other drugs are in a more heavily pretreated patient population and so we’ll be vying for a position in the third or fourth line. Dr. Sandoval Leon is Breast Medical Oncologist at Miami Cancer Institute/ Baptist Health South Florida in Miami, Florida. www.practiceupdate.com/c/65219

Interview with Tanya B. Dorff MD by Farzanna S. Haffizulla MD, FACP, FAMWA Dr. Dorff is Associate Clinical Professor and Head of the GU Cancer Program, City of Hope in Duarte, California. Dr. Haffizulla: Let’s talk a little bit about evidence- based chemotherapy for oligometastatic prostate

cancer. You have recently written about chemo for patients with this disease state. What does the literature say about efficacy of chemo for this patient population? Dr. Dorff: Our main sources of data include the CHAARTED, STAM- PEDE, and LATITUDE trials. So, CHAARTED looked primarily at high-volume disease, which they define as 4 or more bone metas- tases with 1 outside the axial skeleton or visceral involvement. They ended up adding in lower-volume patients out of practicality, but really those patients, even with continued maturation of the data seemed to not benefit from the upfront chemotherapy. This is in contrast to LATITUDE and STAMPEDE with abiraterone, where there seems to be benefit in a broader proportion of patients even that oligometastatic subgroup. So there’s not a lot that we know about this subgroup, especially with chemotherapy, but I think most of us have preferred to use, now that we have an alternative inten- sification with abiraterone, we’ve preferred to use that for these lower-volume patients. Dr. Haffizulla: What are some clinical characteristics that might predict benefit for chemo in this setting? Dr. Dorff: I think there’s still that clinician’s intuition. So a patient who has maybe a low PSA with high-volume disease or a Gleason 10, someone where we anticipate maybe not as much hormonal responsiveness. Now this is not data-based, but I think there’s still room for people to say I know this patient only has one or two metas- tases, they don’t meet the criteria for high volume, but my intuition is telling me that they’ve got bad disease and I want to intensify and I think it’s okay to use chemotherapy for those patients. Dr. Haffizulla: Thank you for telling me that because that’s an important note for our viewership. Besides chemotherapy, what are some alternative strategies for managing these patients? Dr.Dorff: There’s a lot of interest in whether we should add local therapy to the oligomet. So shouldwe do some stereotactic radiation? If they’re lymph nodemets shouldwe be removing them? There are really single institutions, small retrospective series right now, but there are going to be a few national trials launching to ask this very important question both treating the primary in some of the clinical trials and then whether to treat the metastases as well in some of the other trials.

Dr. Caudle is a Board-Certified Family Medicine Physician and Assistant Professor in the Department of Family Medicine at Rowan University-School of Osteopathic Medicine in Stratford, New Jersey.

Dr. Haffizulla is the Assistant Dean of Community and Global Health at Nova Southeastern University’s College of Allopathic Medicine. She practices general internal medicine in Davie, Florida, within her own internal medicine concierge practice.

Go to www.practiceupdate.com/c/65257 to watch this interview with Dr. Herrmann.

Go to www.practiceupdate.com/c//64205 to watch this interview with Dr. Dorff.

VOL. 2 • NO. 4 • 2018