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Educating physicians about PSA reduction goals may increase the number of patients with mCSPC receiving first-line treatment intensification.

Pivotal trials and guidelines recommend a doublet or triplet regimen as standard of care for patients with metastatic castration-sensitive prostate cancer (mCSPC). Findings from an Adelphi Real World retrospective survey of practice patterns among US physicians, however, showed that less than one-third of patients received first-line treatment intensification with an androgen receptor pathway inhibitor (ARPI), docetaxel, or both.

To investigate physicians’ beliefs about treatment intensification for mCSPC in order to understand the gap between evidence-based guidelines and clinical practice, Neeraj Agarwal, MD, and colleagues surveyed 107 US-based urologists and medical oncologists from 2018 to 2022 on their current practices. The findings were published in JAMA Network Open.

According to the physicians surveyed,  of 617 patients, 490 (69.7%) did not receive first-line treatment intensification with ARPIs and/or chemotherapy. An additional 26.9% received delayed treatment intensification in subsequent therapy for mCSPC.

Physicians’ top self-reported reasons for first-line mCSPC treatment choice for both treatment intensification and no treatment intensification were tolerability (64.7% vs 58.6%, respectively; P=0.18) and following recommendations provided in guidelines (61.5% vs 53.5%; P=0.08). For patients whose physicians did not prescribe an ARPI or any subsequent lines of therapy, lack of understanding of survival benefit in clinical trials (31.4%) and tolerability concerns (38.2%) were the most cited reasons for not prescribing an ARPI.

In the bivariate analysis, physicians seeking to reduce prostate-specific antigen (PSA) by 75% to 100% were more prone to provide first-line treatment intensification compared with physicians who targeted to lower PSA by 0% to 49% (odds ratio, 1.63; 95% CI, 1.04-2.56; P=0.03). The researchers found that 85% of physicians perceived PSA reduction by 50% as adequate; 51.4% reported a median goal of 2.0 ng/mL as adequate.

“These goals are unjustified, as they are far from achieving a maximal PSA reduction to undetectable levels (ie, <0.2 ng/mL), which has retrospectively demonstrated clinical benefits compared with less-stringent PSA goals,” wrote the researchers. “Educating physicians about PSA reduction goals may increase the number of patients receiving first-line TI [treatment intensification] in mCSPC and may improve patient outcomes.”

They authors noted that physicians’ concerns about insurance reimbursement and access were not associated with  prescribing and not prescribing treatment intensification.

“Improving physicians’ knowledge of guideline-based therapies, increasing understanding of TI [treatment intensification] clinical trial data, and using appropriate PSA target goals may help overcome the low rates of first-line TI in mCSPC and thereby may improve patient outcomes,” the authors concluded.