Most men with metastatic castration-sensitive prostate cancer (mCSPC) in 2018 did not receive advanced therapies in addition to androgen deprivation therapy (ADT) as first-line treatment for their disease as recommended by clinical practice guidelines, according to real-world data presented at the American Society of Clinical Oncology 2021 virtual annual meeting.

This lack of therapeutic intensification was more pronounced among Black men than non-Hispanic White men, the study revealed.

Possible reasons for the underuse of advanced therapies include patient or disease characteristics, physician awareness, therapeutic inertia, and cost, according to investigators led by Stephen J. Freedland, MD, of Cedars-Sinai Medical Center in Los Angeles and Durham VA Medical Center in Durham, North Carolina.

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“For years, we’ve known that ADT is the standard treatment for mCSPC,” Dr Freedland said in a video presentation. “However, in more recent years, randomized trials have shown that adding either docetaxel or novel hormonal therapies — such as apalutamide, abiraterone, and enzalutamide — to ADT can significantly improve survival.”

Although National Comprehensive Cancer Network (NCCN) treatment guidelines recommend ADT in combination with docetaxel (DOC) or novel hormonal therapies (NHTs) for patients with mCSPC, data on real-world utilization of mCSPC therapies and survival after DOC and NHT introduction are limited, as is evidence of potential racial disparities, Dr Freedland’s team noted.

The investigators analyzed data from 35,209 men with mCSPC in the Medicare database (2010 to 2018). Of these, 1060 (3.0%) received ADT plus NHTs, 1244 (3.5%) received ADT plus DOC, 8446 (24%) received ADT plus nonsteroidal antiandrogens (NSAAs), and 24,459 (69.5%) received ADT alone as first-line treatment.

In 2018, despite the NCCN guideline recommendations, the vast majority (66%) of patients received ADT alone as first-line treatment, whereas only 12.4% of patients received ADT plus NHT, 4.1% received ADT plus DOC, and 17.4% received ADT plus NSAAs.

The rate of treatment intensification with ADT plus NHT varied by race and ethnicity. The rate was higher among non-Hispanic White men (increasing from 6.2% in 2017 to 13.0% in 2018) and Hispanic men (increasing from 6.2% in 2017 to 12.4% in 2018) compared with Black men (increasing from 6.3% in 2017 to 8.3% in 2018). The odds of treatment intensification were 40% lower among Black men and 32% lower among Hispanic men compared with non-Hispanic White men.

Disclosure: Pfizer and Astellas Pharma, co-developers of enzalutamide, funded the study. Please see the original reference for a full list of disclosures.


Freedland SJ, Agarwal N, Ramaswamy K, et al. Real-world utilization of advanced therapies and racial disparity among patients with metastatic castration-sensitive prostate cancer: a Medicare database analysis. Presented at: ASCO 2021 virtual annual meeting held June 4-8. Poster 5073.