Double cross.

Top Line: The treatment of metastatic castration-resistant prostate cancer (mCRPC) is a free for all.

The Study: The decision point for further androgen-axis blockade versus docetaxel may hinge on the extent of metastatic disease—typically low volume, non-visceral versus high volume or visceral—as officially recommended for castration-sensitive disease. If you’re really inquisitive, you might even turn to tumor sequencing. Ok, so you make the educated decision for further androgen blockade. Now what?! Is it abiraterone or enzalutamide you should add? This phase 2 trial was designed with just this question in mind. Remembering that adding one to the other doesn’t help, 202 patients with newly-diagnosed mCRPC were randomized to upfront abiraterone versus enzalutamide with each arm crossing over to the alternative drug upon first PSA progression. The primary endpoint was time from enrollment to time of second PSA progression on the second-line drug. At a median follow-up of almost two years, three-quarters of men in each arm had crossed over, and the median time to second PSA progression was significantly longer when starting with abiraterone and transitioning to enzalutamide (19 months) than vice versa (15 months). This was further supported by rates of PSA responses (of ≥30%) with second-line therapy, which were 36% and 4%, respectively.

TBL: If your decision to use enzalutamide versus abiraterone for mCRPC is based on which one is easier to say, this provides clinical data to sequence them in alphabetical order. | Khalaf, Lancet Oncol 2019