Criteria for Commencement of Next Line Therapy

[PhilipSZacarias]

Most of the oncologists that I have talked to date consider a PSA of 2 ng/ml as the threshold for classifying a patient as castration resistant and before commencing the next line of therapy. A PSA doubling time of <10 months, elevated LDH and ALP values and metastatic progression are other criteria.

It is logical to assume that commencement of next line therapy when the PSA is low (e.g., 0.5 – 2 ng/ml) is more efficacious than when started at a later stages in the disease when PSA is higher (e.g., 2 – 10 ng/ml) , assuming that PSA correlates with disease burden (except in neuroendocrine disease). I am having difficulty finding papers that compared the outcomes of therapies, such as chemotherapy, abiraterone, enzalutamide or SBRT, which were started late vs early. If any member is aware of published literature describing the aforementioned, it would be greatly appreciated.

In my opinion, the next line therapy should be started when the PSA is increasing with a doubling time <10 months and less than 2 ng/ml. Furthermore, it would seem to make more sense to start abiraterone therapy, for example, when the PSA is increasing and before it reaches 2 ng/ml.

Comments would be appreciated.

Cheers,

Phil

[Tall_Allen]

Here's some early data that suggest an early start is better:

thelancet.com/journals/lano...

[PhilipSZacarias in reply to Tall_Allen]

Much appreciated, Tall_Allen!!

[PhilipSZacarias in reply to Tall_Allen]

Have you come across to anything related to starting abiraterone or enza early?

[Tall_Allen in reply to PhilipSZacarias]

No - there is a clinical trial of Zytiga ± Erleada for BCR

[tallguy2]

I agree with you. I have a doubling time of 3 months with a current PSA of 1.2. My research MO is recommending immediate action (in my case abiraterone plus a trial drug) ...why wait until 2.0 when the "handwriting is on the wall?"

[PhilipSZacarias in reply to tallguy2]

A consensus of two so far...