treatment options

Oncologist vs Urologist Treatment Decision-Making for Metastatic Castration–Sensitive Prostate Cancer in the United States

Study findings presented at the 2022 ASCO Annual Meeting reveal oncologists’ and urologists’ reasons for underutilization of treatment intensification for patients with metastatic castration–sensitive prostate cancer.

“Based on level 1 evidence of overall survival, ASCO/NCCN/AUA guidelines uniformly recommend novel hormonal therapy or chemotherapy added to androgen deprivation therapy (ADT) as standard of care in [metastatic castration–sensitive prostate cancer],” wrote Stephen Freeland, MD, Cedars-Sinai Medical Center, and Durham Veterans Affairs Health Care System, and colleagues.

“However, real-world evidence across US health care systems suggests most patients receive ADT [with or without] first generation non-steroidal antiandrogens,” they added.

Data from medical charts of at multiple US academic and community practices were used to examine the reasons behind the lack of treatment intensification among patients with metastatic castration–sensitive prostate cancer. Data from patients initiating treatment from July 2018 to November 2021 were included. Researchers surveyed the oncologists and urologists treating these patients in order to describe reasoning behind treatment decisions, including prostate specific antigen (PSA) goals.

Overall, 65 oncologists and 42 urologists completed the survey and data on 621 patients were included in the study. The median patient age at treatment start was 68 years, 58% of patients were White and 25% were Black, 84% had de novo metastases, 30% had high-volume disease including 22% with visceral metastases, and 83% had ECOG performance score ≤1.

In the first-line setting, the majority of patients (69%) received ADT with or without non-steroidal antiandrogens alone, while rates of treatment intensification with ADT plus novel hormonal therapy (26%) or ADT plus chemotherapy (4%) were low at 26% and 4%, respectively. In addition, 27% of patients received subsequent treatment intensification while castration sensitive.

Findings from the physician survey revealed the 5 top reasons their patients did not receive initial novel hormonal therapy were perceptions about: (1) drug tolerability (38%), (2) lack of clinical trial evidence of overall survival improvement (31%), (3) lack of reimbursement (26%), (4) patient financial constraints (20%), and (5) questions about sequencing novel hormonal therapies earlier vs later in disease course (21%).

For PSA goals, physicians more frequently reported a relative reduction (85%) vs an absolute PSA reduction (51%). Oncologists considered a median PSA reduction of 50% adequate vs 75% with urologists.

In addition, urologists had higher rates of treatment intensification in the first-line setting and beyond in patients who were still castration sensitive. Physicians who had goals for PSA reduction of 75% to 100% were more likely (OR = 1.63; P = .034) to provide treatment intensification in the first-line setting vs those with less aggressive PSA goals.

“To our knowledge, this is the first study identifying reasons for underutilization of intensified treatment in [metastatic castration–sensitive prostate cancer]. While survey results suggest perceptions of tolerability and lack of efficacy and financial considerations affect [novel hormonal therapy] use, in practice, non-guideline driven PSA reduction goals are associated with low rates of [treatment intensification],” concluded Dr Freedland and colleagues.



Freedland SJ, Klaassen ZWA, Agarwal N, et al. Reasons for oncologist and urologist treatment choice in metastatic castration-sensitive prostate cancer (mCSPC): A physician survey linked to patient chart reviews in the United States. Abstract presented at: ASCO Annual Meeting; June 3-7, 2022; Chicago, IL, and virtual. Abstract 5065.


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