Another bit of dogma bites the dust….. “Castration resistant prostate cancer”
I don’t use the word paradigm, as I can’t be sure of the spelling, and I’m not totally confident about its meaning! I suspect I’m not alone in this. Should you have been brought up to think of prostate cancer being of two sorts, hormone sensitive and hormone resistant (just like breast cancer), and thought about care plans along the same lines, that might be a paradigm. Though it might not! My thinking was traditionally set in this frame until a couple of months ago when Malcolm Mason lectured at the European Institute of Oncology on “All prostate cancers are hormone sensitive” or some such title.

Malcolm is senior professor of Oncology at the University of Wales in Cardiff, and is THE British expert in clinical research and management of prostate cancer, and also happens to be a concert pianist of some distinction. His take home message was that we have been intellectually lazy in assuming that “castration resistant” prostate cancer was only soluble by non hormonal therapies, none of which, by the way are much good. The idea that androgen resistance might be surpassable by looking at the underlying biology has escaped most urologists. But it didn’t escape Mike Jarman, a professor of chemistry in the drug development group in the Institute of Cancer Research in London. 

Well do I recall him talking about the obvious need to block the CYP17 lyase pathway, which he reckoned (correctly) to be an escape pathway circumventing conventional androgen blockade. He made, if my memory serves me well, the drug of the moment abiraterone. I can’t understand why it’s taken so long to get this drug to Phase 2 trials, but arrived it has. This week’s JCO carries an authoritative Phase 1 study with over 60 patients, demonstrating clear cut responses with the drug (a hormone) in those hormone resistant patients. At last some hope, for those prostate cancer patients who have been condemned to supportive care only or docetaxel, which is barely different, after failure of the conventional “paradigm".

Journal of clinical oncology