patient care perspectives

Balancing Survival and Quality of Life in Asymptomatic Patients With Advanced Prostate Cancer

by William K. Oh, MD


The successful treatment of patients with asymptomatic castration-resistant prostate cancer (CRPC) requires achieving a balance between improving survival and maintaining quality of life. Recent clinical trials have shown that the novel androgen receptor inhibitors apalutamide, enzalutamide, and darolutamide can extend the time to disease progression and improve survival with acceptable toxicities in patients with asymptomatic CRPC.

Expert Commentary

William K. Oh, MD

Chief, Division of Hematology and Medical Oncology
Deputy Director, The Tisch Cancer Institute
Professor of Medicine and Urology
Ezra M. Greenspan, MD Professor in Clinical Cancer Therapeutics
Icahn School of Medicine at Mount Sinai
New York, NY

“A benefit of having different options in the same drug class is that there may be slight differences in their tolerability and side-effect profiles.

William K. Oh, MD

There has been a recent shift in the management of advanced prostate cancer toward earlier initiation of treatment. One result of this change is that patients who are relatively asymptomatic are being treated for longer periods. The benefit of this approach is that patients are living longer with fewer metastases, but they are also facing greater challenges in terms of maintaining quality of life. Although it is reassuring that some of the patient-reported quality-of-life data that have been presented do not show a difference between treatment and placebo, it has been my experience that some patients may experience an increase in fatigue and weakness with drugs such as enzalutamide and apalutamide. Most men do well with these treatments, but there is a small subset of men who does poorly, and weakness is a significant concern owing to the risk of falls and fractures. In some of these individuals, I may lower the dose, interrupt treatment, or consider switching them to an alternative therapy. Our greatest experience is with enzalutamide because this drug has been around the longest. In the asymptomatic CRPC setting, enzalutamide is generally well tolerated, but approximately 5% to 10% of patients experience profound fatigue and/or muscle weakness. In those settings, I will often stop the drug and see whether their symptoms improve or resolve. If they do, I may re-challenge them, either with a lower dose of enzalutamide or I might consider switching to a drug such as abiraterone in the M1 CRPC setting or to apalutamide or darolutamide in the M0 CRPC setting, the latter of which is the newest of the 3 agents. 

A benefit of having different options in the same drug class is that there may be slight differences in their tolerability and side-effect profiles. One of the original ideas with darolutamide was that it might not cross the blood-brain barrier and therefore might not potentiate centrally mediated adverse events such as fatigue. There was an intriguing suggestion that this might be true in ARAMIS (eg, no increase vs placebo in falls, fractures, or seizures). However, we do not know whether apalutamide, enzalutamide, and darolutamide are equivalent in terms of side effects because they have not yet been directly compared. As clinicians, we now have the opportunity to switch between drugs if we think that a patient may tolerate a particular agent better than another.


El-Amm J, Aragon-Ching JB. The current landscape of treatment in non-metastatic castration-resistant prostate cancer. Clin Med Insights Oncol. 2019;13:1179554919833927.

Fizazi K, Shore N, Tammela TL, et al; ARAMIS Investigators. Darolutamide in nonmetastatic, castration-resistant prostate cancer. N Engl J Med. 2019;380(13):1235-1246.

Hussain M, Fizazi K, Saad F, et al. Enzalutamide in men with nonmetastatic, castration-resistant prostate cancer. N Engl J Med. 2018;378(26):2465-2474.

Ritch C, Cookson M. Recent trends in the management of advanced prostate cancer. F1000Res. 2018 Sep 21;7. pii: F1000 Faculty Rev-1513. doi: 10.12688/f1000research.15382.1. eCollection 2018.

Thiery-Vuillemin A, Poulsen MH, Lagneau E, et al. Impact of abiraterone acetate plus prednisone or enzalutamide on fatigue and cognition in patients with metastatic castration-resistant prostate cancer: initial results from the observational AQUARiUS study. ESMO Open. 2018;3(5):e000397.

Tomaszewski EL, Moise P, Krupnick RN, et al. Symptoms and impacts in non-metastatic castration-resistant prostate cancer: qualitative study findings. Patient. 2017;10(5):567-578.

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