An apal a day.

Top Line: Anyone not confused on the best systemic therapy for metastatic castrate-sensitive prostate cancer? 

The Study: Like enzalutamide, apalutamide threw it’s hat in the ring with initial reporting of the phase 3 TITAN trial at ASCO 2019 by demonstrating an improvement in survival when compared to first-generation androgen deprivation therapy (ADT) alone. We now have the final survival analysis here to cement apalutamide as a serious contender for first-line status. Among over 1000 men, the addition of apalutamide to ADT significantly reduced the risk of death by 35%—median overall survival was just over 4 years in the ADT alone arm and not yet reached in the apalutamide arm. The kicker is, when adjusting for crossover which was allowed, the risk of death was actually slashed in half in those receiving apalutamide. What’s more, the addition of apalutamide didn’t result in an additional dip in health-related quality of life. Now the real question is how this all stacks up against other ADT intensification strategies such as docetaxel or abiraterone. Absent a head-to-head comparison, the authors conclude the benefit of apalutamide is all in the side effects, or lack thereof.

TBL: Apalutamide significantly improves survival when added to ADT across a broad population of men with metastatic castrate sensitive prostate cancer and, along with its cousin enzalutamide, provides the only chemo- and steroid-free option for ADT intensification. | Chi, J Clin Oncol 2021