Targeted Drugs Approved as First-line Alternative for Prostate Cancer

Peter Russell

May 06, 2020

Cancer specialists have welcomed a decision to approve targeted hormone therapies enzalutamide (Xtandi, Astellas) and abiraterone (Zytiga, Janssen) as first-line NHS treatments for men with advanced prostate cancer.

The interim measures were approved by NHS England to relieve pressure on the NHS during the COVID-19 pandemic.

The changes permit:

  • An option to give enzalutamide with androgen deprivation therapy for patients with newly diagnosed metastatic disease instead of docetaxel to reduce toxicity and potential for admission

  • An option to switch to abiraterone for patients who are intolerant of enzalutamide

Usual treatment for men when they are first diagnosed with advanced prostate cancer is hormone therapy – either on its own, or in combination with docetaxel chemotherapy.

Docetaxel is normally given as six three-weekly infusions in hospital and can significantly weaken patients' immune system and cause inflammation of the lungs – putting men at risk from COVID-19.

Enzalutamide and abiraterone are given as tablets which men can take at home, avoiding the need for hospital treatment.

Decision 'Overdue'

The Institute of Cancer Research (ICR) said the interim guidance was an example of how modern treatments that can be taken at home could relieve pressure on the NHS during the coronavirus pandemic.

However, it criticised NHS England for taking so long over its recommendation.

It was also critical that guidance limited the use of abiraterone, which ICR scientists helped develop, to patients who were intolerant of enzalutamide.

Enzalutamide is a hormone treatment that blocks the effect of testosterone on prostate cancer cells.

Abiraterone decreases the production of testosterone, which is needed for prostate cancer to grow.

Nick James, professor of prostate and bladder cancer research at the ICR, said it was "frustrating that during this anxious lockdown period it has taken so many weeks to agree extended access to targeted hormone therapies in place of chemotherapy, and that NHS England has chosen to focus on enzalutamide as the initial therapy rather than leaving clinicians to decide on an individual patient basis".

Abiraterone was licensed as a first-line treatment by the European Medicines Agency in 2017, and was recommended in Scotland as a first-line treatment for advanced prostate cancer earlier this year.

However, in England and Wales, it has only been available to treat men for whom hormone therapy has stopped working.

Call to Modernise Cancer Treatment

Prof James said: "I'm pleased and relieved that many more men should now benefit from targeted hormone therapies right from when they are first diagnosed. They are smarter, kinder treatments, and could extend the lives of many more patients.

"Offering enzalutamide or abiraterone to men as first-line treatment for prostate cancer will greatly lower the risk of exposing vulnerable patients to the coronavirus, and lightens the load on our hard-pressed hospitals."

He added: "It's becoming increasingly clear that the COVID-19 pandemic will have a long-term impact on the way we live our lives, and I would urge NHS regulators to consider other areas in which cancer care can be modernised, to move towards managing patients at home where possible."

The interim treatment changes are for an initial 3-month period beginning on 23rd April 2020. Treatment regimens will revert to the standard commissioned position after this period unless guidelines are updated.

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