b'Treatment Options Expand for Older Veterans With Castration-Resistant PCaIn most recurrent prostate cancer patients, androgen-deprivation therapy works for a while. Eventually, however, most men end up developing castration-resistant prostate cancer. Now, expanding treatment options are especially benefiting older men in that situation, who often didnt fare well with chemotherapy.By Annette M. BoylePORTLAND, OREvery year, about 15,000 vet- metastatic CRPC (mCRPC), as is abiraterone. The erans develop prostate cancer, with the risk of themajority (86%) of men with mCRPC initially had disease rising sharply with age. For the 20% to 30%nmCRPC that became metastatic rather than initially of veterans who will experience a recurrence of thepresenting with metastatic disease, Graff and Feng cancer following initial surgery or radiation, the op- wrote. Delaying the time to metastasis is critically tions for treatment have been fairly limited becauseimportant.of concerns about comorbidities, frailty and inabilityA pooled analysis of clinical trials of second-gen-to tolerate chemotherapy.eration androgen receptor inhibitors performed by The first-line treatment for recurrent prostate can- investigators in the FDAs Office of New Drugs and cerisandrogen-deprivationtherapy(ADT),whichpublished in Lancet Oncology found that, in patients induces medical castration. More than 90% of recur- with nonmetastatic CRPC who had a prostate-spe-rent or metastatic cancer patients respond to ADT ini- cific antigen doubling time of less than 10 months tially, but, in time, nearly all men on the therapy willandwere80yearsofageorolder,theestimated develop castration-resistant prostate cancer (CRPC).median metastasis-free survival was 40 months in Fortunately,theoptionsavailableforveteransthe androgen receptor inhibitor arms and 22 months with CRPC have dramatically expanded in recentin the placebo arms, for an adjusted risk reduction of years, and recent studies show that these options63%. Those results compared well with the median are effective and suitable even for men in their 80s.metastasis-free survival seen in younger men of 41 The older population has a higher risk of prostatemonthsintheandrogenreceptorinhibitorgroups cancer morbidity and mortality and has unique issuesand 16 months in the placebo groups, for an adjusted around drug tolerability, metabolism, and polyphar- reduction in metastasis risk of 69%. 2macy, noted Julie Graff, of the VA Portland HealthThemedianoverallsurvivalinpatientsaged80 Care System, and her colleague at the Oregon Healthand older was 54 months in the intervention groups & Science University in Portland, Zizhen Feng. Thecompared to 49 months in the placebo groups, for a rise of nonchemotherapy treatment options for pros- 21% reduction in mortality risk. That compared to tate cancer gives men more treatment options, par- 74 months in the next-generation androgen receptor ticularly for those patients who are not suitable forgroups and 61 months for the placebo groups in men chemotherapy. 1 younger than age 80.Three second-generation androgen receptor inhibi-tors are indicated for nonmetastatic CRPC (nmCRPC)Advantages and Challengesin conjunction with continued ADTapalutamide,While the recent approvals provide a welcome al-darolutamideandenzalutamide.Apalutamideandternative to often difficult-to-tolerate chemotherapy enzalutamide are also approved for use in men withand also offer benefits in terms of progression-free 110'