DR GEORGE: So Neil, in my practice, I look at my patients in terms of 2 things. I look at in terms of symptoms, and then I look at it in terms of tumor volume. And how I judge tumor volume is how their bone scans look, not necessarily the reports. I actually look at the scans. I look at their tumor burden on CT scan. And I look at the PSA level. And, to some extent, I look at that rate of rise of PSA.

And my first choice in these patients, if they’re willing to do it, is sipuleucel-T. And the reason for that is because this is a 1-time therapy. It’s a 1-month therapy. It’s a therapy with a proven survival benefit. And it’s a therapy that I know that isn’t going to select for resistance to subsequent lines of therapy with other hormonal agents or chemotherapy agents. So it’s not changing the biology of the disease the way other agents change the biology. And it’s something that isn’t associated with long-term side effects, and yet it does have a survival benefit.

So to me, it’s a very attractive option in patients who have that window. But if they’ve got higher burden of disease, if they’ve got symptomatic disease, if they’ve got rapid PSA-rising disease that I’m concerned about in combination with that volume, that’s when I may consider starting a secondary hormonal therapy to get that under control and then add in sipuleucel-T. So to me, it’s really about those characteristics, the symptoms, PSA kinetics and tumor volume, kind of helping guide where I put sipuleucel-T versus secondary hormonal therapy.

If patients are on the other end of the spectrum, if patients have symptomatic, high-volume metastatic disease, then I’m thinking about using my secondary hormonal therapies up front and not really using sipuleucel-T at all. And there the only question is, how are they going to respond to that agent versus going straight to chemotherapy? In the situations where I’ll go straight to chemotherapy, typically in the ones who have very low PSAs, patients what I think are more anaplastic tumors.

And in those patients who have more radiographic or clinical progression without a lot of PSA level, say, less than 5, that’s where I’m getting a little bit more concerned — could they have a more anaplastic type? And I’m going to want to use chemotherapy sooner rather than later, particularly if they’re symptomatic. So that’s a relatively rare population, thankfully. Most of our patients are falling into 1 of the first 2 scenarios, and I usually have time in, I’d say, probably 75% of my population to treat with sipuleucel-T first if they’re willing to do it.

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Checkpoint inhibitors