The correlation between metastasis-free survival and overall survival in non-metastatic castration resistant prostate cancer patients from the Medical Data Vision claims database in Japan

Improving the identification of high-risk non-metastatic castration-resistant prostate cancer patients in clinical practice

Non-metastatic castration-resistant prostate cancer (nmCRPC) represents a challenging disease state in prostate cancer care. nmCRPC patients with a high risk of progression to metastatic disease who are identified by a prostate-specific antigen doubling time (PSADT) ≤10 months are eligible for treatment with the novel androgen receptor inhibitors (ARIs), shown to delay disease progression and extend survival. However, nmCRPC is often unexploited in clinical practice due to a lack of standardization in the methodology and in the tools used for its identification. In this article, a group of Urology and Oncology specialists with acknowledged expertise in prostate cancer reviews the state of the art in the management of high-risk nmCRPC patients, identifies gaps and unmet needs, and proposes strategies to optimize the identification of this patient subgroup in the clinical practice and improve their health outcomes.

Impact of body mass index on in-hospital mortality in older patients hospitalized for bacterial pneumonia with non-dialysis-dependent chronic kidney disease

BACKGROUND

Low body mass index (BMI) in older individuals with decreased kidney function is important because of its association with poor prognosis and frailty. Herein, we aimed to clarify the association between BMI and in-hospital mortality among older patients with non-dialysis-dependent chronic kidney disease (CKD) stratified by kidney function.

METHODS

Using data from the Medical Vision Database, this multicentre cohort study included people aged ≥ 60 years with an estimated glomerular filtration rate of < 60 ml/min/1.73 m² but without dialysis dependency, hospitalised for bacterial pneumonia during 2014-2019. We compared the risk of in-hospital death between patients with BMI categories based on the quartiles (low, medium-low, medium-high, and high) setting medium-high BMI as a reference. We further assessed the association with BMI using a cubic spline, setting BMI as a nonlinear continuous variable and a BMI of 22 kg/m² as a reference. We also evaluated the association between BMI and kidney function using a generalised additive model adjusted for interaction terms between nonlinear continuous BMI and kidney function.

RESULTS

We obtained data for 3,952 patients, with 350 (8.9%) in-hospital deaths. When compared with medium-high BMI, low BMI was associated with an increased risk of death and longer hospital stay, whereas the other two categories were comparable. Models using a cubic spline showing an association between BMI and in-hospital death showed an L-shaped curve; BMI < 22.0 kg/m² was associated with an increased risk for mortality, and at a BMI of 18.5 kg/m², the odds ratio was 1.43 with a 95% confidence interval of 1.26-1.61 when compared with a BMI of 22.0 kg/m². Analysis of the interactive effects of kidney function using the generalised additive model showed that a protective association of high BMI tapered along with decreased kidney function.

CONCLUSIONS

This cohort study suggests not only that lower BMI and low kidney function are associated with in-hospital mortality independently but also that the protective effects of high BMI weaken as kidney function decreases via the analysis of the interaction terms. This study highlights the necessity for the prevention of underweight and demonstrates the interaction between BMI and kidney function in older patients with non-dialysis-dependent CKD.

Administration of radium-223 and the prognosis in Japanese bone metastatic castration-resistant prostate cancer patients: A large database study

BACKGROUND

The ALSYMPCA trial revealed radium-223 (Ra-223) to be a life-prolonging agent for bone metastatic castration-resistant prostate cancer (CRPC). However, only 2.8% of enrolled patients in that clinical trial were Asian, and no Japanese patients were enrolled. Several retrospective studies have been published concerning Japanese bone metastatic CRPC patients receiving Ra-223. However, no study has yet reported the correlation between Ra-223 induction and the survival in Japanese bone metastatic CRPC patients. This study investigated the effect of Ra-223 as a life-prolonging agent in a large Japanese healthcare fee database.

METHODS

A total of around 410 000 prostate cancer patients were extracted from this database, and 25 934 were diagnosed with CRPC. In these patients, the age, date of the CRPC diagnosis, date of Ra-223 induction, and prognosis were analyzed.

RESULTS

A total of 1628 patients received Ra-223, and 6693 patients were diagnosed with bone metastasis CRPC, with the remaining 17 613 patients diagnosed with CRPC without bone metastasis. The patients who completed six courses of Ra-223 showed a significantly more favorable overall and cancer-specific survival than those who received ≤5 courses (p < 0.0001 and p < 0.0001, respectively). For time from CRPC diagnosis date to death, the Ra-223 induction group showed a significantly more favorable prognosis with regard to both the overall and cancer-specific survival than the bone metastatic CRPC patients without Ra-223 (p < 0.0001 and p < 0.0001, respectively).

CONCLUSIONS

Bone metastatic CRPC patients who received Ra-223 showed a significantly better prognosis than bone metastatic CPRC patients who did not receive Ra-223.

Radiotherapy plus androgen-deprivation therapy for PSA persistence in lymph node-positive prostate cancer

The treatment for lymph node involvement (LNI) after radical prostatectomy (RP) has not been established. This study aimed to reveal the outcomes of various management strategies among patients with LNI after RP. Retrospectively, 561 patients with LNI after pelvic lymph node dissection (PLND) with RP treated between 2006 and 2019 at 33 institutions participating in the Japanese Urological Oncology Group were investigated. Metastasis-free survival (MFS) was the primary outcome. Patients were stratified by PSA persistence after RP. Cox regression models were used to analyze the relationships between clinicopathological characteristics and survival. Survival analyses were conducted using the Kaplan-Meier method and log-rank test with or without propensity score matching. Prognoses, including MFS and overall survival, were prominently inferior among patients with persistent PSA than among those without persistent PSA. In multivariate analysis, androgen-deprivation therapy (ADT) plus radiotherapy (RT) was associated with better MFS than ADT alone among patients with persistent PSA (hazard ratio = 0.37; 95% confidence interval = 0.15-0.93; P = 0.034). Similarly, MFS and overall survival were significantly better for ADT plus RT than for ADT alone among patients with persistent PSA after propensity score matching. This study indicated that PSA persistence in LNI prostate cancer increased the risk of poor prognoses, and intensive treatment featuring the addition of RT to ADT might improve survival.

Impact of COVID-19 pandemic on healthcare service use for non-COVID-19 patients in Japan: retrospective cohort study

OBJECTIVES

We aimed to investigate the impact of the first and second waves of the COVID-19 pandemic on healthcare service use by non-COVID-19 patients.

DESIGN

Retrospective cohort study.

SETTING

Hospital-based claims database from anonymised hospitals in Japan.

PARTICIPANTS

Patients (n=785 495) who visited and/or were hospitalised in 26 anonymised hospitals in Japan between January 2017 and November 2020.

OUTCOME MEASURES

We compared changes in the monthly number of hospitalisations (overall or by diagnosis), outpatient visits, endoscopic fibrescopies (EFs), rehabilitations, outpatient chemotherapy treatments, maintenance haemodialysis treatments and outpatient prescriptions between pre-COVID-19 years and the same period in 2020.

RESULTS

The overall number of hospitalisations and outpatient visits decreased by 27% and 22%, respectively, in May 2020, of which the most substantial decrease was observed in the paediatrics department (65% and 51%, respectively). The number of hospitalisations for respiratory diseases, circulatory diseases, malignant neoplasms and digestive diseases decreased by a maximum of 55%, 32%, 10% and 26%, respectively, in 2020. The number of hospitalisations for non-COVID-19 pneumonia in patients aged <16 years, patients aged ≥16 years and patients with asthma decreased by 93%, 43% and 80%, respectively, in May 2020. EFs and outpatient rehabilitations decreased by >30%. In contrast, outpatient chemotherapy and maintenance haemodialysis treatments decreased by <10%, if at all. Outpatient prescriptions decreased by a maximum of 20% in 2020, with the largest decrease observed in drugs for obstructive airway diseases and cough and cold preparations.

CONCLUSIONS

The use of healthcare services by non-COVID-19 patients was most affected during the first wave of the COVID-19 pandemic in May 2020. The number of hospitalisations for respiratory diseases, particularly non-COVID-19 pneumonia and asthma, drastically decreased, while the number of hospitalisations and outpatient chemotherapies for malignant neoplasms or maintenance haemodialysis was less affected.

Postoperative Pain Treatment in Patients with Dementia: A Retrospective Observational Study

BACKGROUND

Inadequate postoperative analgesia has been noted in patients with dementia, but this topic has only been studied in hip fractures. This study aimed to examine whether the duration of postoperative analgesia associated with three surgical procedures was shorter in patients with dementia than in those without dementia.

METHODS

This retrospective observational study was based on a nationwide discharge database of acute care hospitals in Japan and included patients aged ≥ 65 years diagnosed with lung cancer, rectal cancer, or hip fracture, who underwent surgery in 366 hospitals between April 2013 and September 2018. The primary outcome was the incidence of injectable analgesic use during the postoperative hospital stay. The number of person-days of opioid, non-steroidal anti-inflammatory drug, or acetaminophen use was calculated for patients with and without dementia after each surgery using generalized estimating equations to obtain the age-adjusted incidence per 100 person-days.

RESULTS

Among the 32,379 patients included, 4828 (14.9%) had dementia. The duration of opioid administration per 100 person-days was 14% shorter in patients with dementia than in those without dementia after open rectal cancer surgery (incidence rate ratio [IRR] 0.86; 95% confidence interval [CI] 0.74-1.00) and 20% shorter in patients with dementia after open lung cancer surgery (IRR 0.80; 95% CI 0.70-0.91). In patients who underwent thoracoscopic lung cancer surgery, laparoscopic rectal cancer surgery, or hip replacement surgery, the duration of opioid administration was shorter in patients with dementia than in those without dementia, but the difference was not statistically significant.

CONCLUSIONS

The length of postoperative opioid administration after lung and rectal cancer surgery was reduced in patients with dementia, suggesting that the duration of postoperative analgesia in patients with dementia may be insufficient. More careful pain assessment and management of postoperative analgesia in these patients may be necessary.

Treatment Pattern for Advanced Gastric Cancer in Japan and Factors Associated with Sequential Treatment: A Retrospective Administrative Claims Database Study

Introduction

Clinical trials have proven the efficacy and safety of new therapies for advanced gastric cancer (AGC), but how those therapies are used in the real world is poorly described. Real-world treatment patterns of antitumor therapies and factors associated with overall therapy duration in patients with AGC in Japan were investigated.

Methods

This retrospective cohort study used a Japanese administrative claims database (June 2014 to September 2019). Patients with AGC who started the guideline-recommended first-line combination regimens with platinum and fluoropyrimidine agents between June 2015 and July 2019 were included. Cox regression analysis was performed to identify factors associated with overall therapy duration (first line to last administration of guideline-listed agent).

Results

Of the 10,581 patients included, the most common first-line combination regimen without trastuzumab was S-1 plus oxaliplatin (4327/9069 patients; 47.7%) and with trastuzumab was capecitabine plus cisplatin (608/1512 patients; 40.2%). Most common second- and third-line regimens were ramucirumab plus taxane (3650/5358 patients; 68.1%) and nivolumab (1229/2390 patients; 51.4%), respectively. Factors positively associated with longer overall therapy duration were: oral fluoropyrimidine in first line (hazard ratio [95% confidence interval]: 0.63 [0.57–0.69]); trastuzumab in any line (0.73 [0.68–0.78]); treatment at a designated cancer hospital (0.89 [0.84–0.94]); dietary consultation within 1 month before/after start of first line (0.92 [0.86–0.98]); and treatment at a surgical department (0.94 [0.89–0.99]). Negatively associated factors were: edema (1.21 [1.07–1.37]); physical therapy (1.21 [1.12–1.31]); nutritional intervention (1.21 [1.14–1.28]) within 1 month before/after start of first line; thrombosis (1.13 [1.04–1.23]); renal disease (1.11 [1.02–1.21]); age (1.07 [1.02–1.13]); and peritoneal metastasis/ascites (1.06 [1.01–1.13]).

Conclusions

In real-world treatment practice for AGC in Japan, therapy choice after the recommended first-line chemotherapy was consistent with guidelines. Factors associated with overall therapy duration were identified, which may assist in optimizing treatment sequence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01931-3.

Evidence-based Urology: Surrogate Endpoints-Con

Surrogate endpoints have the potential to expedite results from clinical trials. However, a surrogate endpoint may not always be a patient-important outcome. Surrogate endpoints must be validated to ensure that they do not expose patients to unnecessary treatment-related toxicity.

Effectiveness of Vintage Hormone Therapy as Alternative Androgen Deprivation Therapy for Non-metastatic Castration-resistant Prostate Cancer

BACKGROUND/AIM

Vintage hormone therapy for non-metastatic castration-resistant prostate cancer (nmCRPC) is not recommended under the current guidelines, but is widely practiced in Japan. This study assessed effectiveness of vintage hormone therapy as alternative androgen deprivation therapy (AADT) for treatment of nmCRPC.

PATIENTS AND METHODS

In this retrospective study we examined patients with nmCRPC that received vintage hormone therapy as AADT between 1999 and 2018.

RESULTS

Of 53 patients with nmCRPC, 25 patients (47.2%) had stage 1 nodal disease (N1) at diagnosis of nmCRPC. Prostate specific antigen (PSA) reduction rate≥30% was observed in 32 patients (72.7%). The median PSA nadir was 0.7, and the duration of the response was 14.3 months. The median metastasis-free survival (MFS) for the entire patient population was 62.2 months, and the median overall survival (OS) was not reached. In the multivariate analysis, the duration of response in AADT>18 months was a predictor of prolonged OS.

CONCLUSION

There is a certain number of nmCRPC patients who respond well to vintage hormone therapy as AADT. Further studies are expected to differentiate such cases.

Current Status and Future Perspectives of Androgen Receptor Inhibition Therapy for Prostate Cancer: A Comprehensive Review

The androgen receptor (AR) is one of the main components in the development and progression of prostate cancer (PCa), and treatment strategies are mostly directed toward manipulation of the AR pathway. In the metastatic setting, androgen deprivation therapy (ADT) is the foundation of treatment in patients with hormone-sensitive prostate cancer (HSPC). However, treatment response is short-lived, and the majority of patients ultimately progress to castration-resistant prostate cancer (CRPC). Surmountable data from clinical trials have shown that the maintenance of AR signaling in the castration environment is accountable for disease progression. Study results indicate multiple factors and survival pathways involved in PCa. Based on these findings, the alternative molecular pathways involved in PCa progression can be manipulated to improve current regimens and develop novel treatment modalities in the management of CRPC. In this review, the interaction between AR signaling and other molecular pathways involved in tumor pathogenesis and its clinical implications in metastasis and advanced disease will be discussed, along with a thorough overview of current and ongoing novel treatments for AR signaling inhibition.

Treatment patterns in pancreatic cancer patients based on a hospital claims database in Japan

BACKGROUND

Pancreatic cancer treatment is evolving, but few studies have examined a nationwide trend in the treatment patterns. The purpose of this study was to clarify real-world treatment patterns for pancreatic cancer in Japan.

METHODS

This retrospective study examined the treatment patterns among 68 479 patients, who had pancreatic cancer diagnosis in Medical Data Vision claims database from 2010 to 2018. We extracted relevant data on treatment options, including chemotherapy, surgery and their combination. For patients who had undergone chemotherapy, we sought to analyse the use of different chemotherapy regimens. In addition, we examined the trend in treatment patterns by age group (<59, 60-69, 70-79, ≥80).

RESULTS

The trend in treatment options of pancreatic cancer remained stable from 2010 to 2018, with chemotherapy being the most common therapeutic option and surgery performed in approximately half that of chemotherapy. On the other hand, the use of chemotherapy regimen had changed during the same period. Although gemcitabine was the most commonly administrated single-agent regimen in 2010, gemcitabine + nab-paclitaxel was the most frequently used therapeutic agent in 2018. In the older age groups (age ≥80), the majority of patients was untreated (supposedly received supportive care), and the use of conventional regimens such as gemcitabine or S-1 was common among those undergoing chemotherapy.

CONCLUSIONS

Although chemotherapy has been the main treatment option for pancreatic cancer, the regimens of choice have increased significantly during the last decade. With accumulating evidence on combination chemotherapy, treatment options may further evolve in the future.

Treatment of nonmetastatic castration-resistant prostate cancer: focus on second-generation androgen receptor inhibitors

BACKGROUND

Nonmetastatic castration-resistant prostate cancer (nmCRPC) is defined as a rising prostate-specific antigen concentration, despite castrate levels of testosterone with ongoing androgen-deprivation therapy or orchiectomy, and no detectable metastases by conventional imaging. Patients with nmCRPC progress to metastatic disease and are at risk of developing cancer-related symptoms and morbidity, eventually dying of their disease. While patients with nmCRPC are generally asymptomatic from their disease, they are often older and have chronic comorbidities that require long-term concomitant medication. Therefore, careful consideration of the benefit-risk profile of potential treatments is required.

METHODS

In this review, we will discuss the rationale for early treatment of patients with nmCRPC to delay metastatic progression and prolong survival, as well as the factors influencing this treatment decision. We will focus on oral pharmacotherapy with the second-generation androgen receptor inhibitors, apalutamide, enzalutamide, and darolutamide, and the importance of balancing the clinical benefit they offer with potential adverse events and the consequential impact on quality of life, physical capacity, and cognitive function.

RESULTS AND CONCLUSIONS

While the definition of nmCRPC is well established, the advent of next-generation imaging techniques capable of detecting hitherto undetectable oligometastatic disease in patients with nmCRPC has fostered debate on the criteria that inform the management of these patients. However, despite these developments, published consensus statements have maintained that the absence of metastases on conventional imaging suffices to guide such therapeutic decisions. In addition, the prolonged metastasis-free survival and recently reported positive overall survival outcomes of the three second-generation androgen receptor inhibitors have provided further evidence for the early use of these agents in patients with nmCRPC in order to delay metastases and prolong survival. Here, we discuss the benefit-risk profiles of apalutamide, enzalutamide, and darolutamide based on the data available from their pivotal clinical trials in patients with nmCRPC.

Prostate Cancer in Latin America: Challenges and Recommendations

Prostate cancer (PCa) is the most frequent tumor among Latin American (LATAM) men. The incidence of de novo metastatic PCa is higher in LATAM than other parts of the world, and demographic changes in the region have increased disease burden. However, region-specific information regarding prevalence, progression, and treatment effectiveness is not currently available for nonmetastatic, castration-resistant PCa (nmCRPC). Nonmetastatic, castration-resistant PCa is a heterogeneous disease with varying potential to develop metastasis with limited treatments available, until recently. New clinical trials with promising results have allowed second-generation antiandrogen drugs to be used as first-line treatments, rendering guidelines outdated. As a result, this panel of experts reviewed the current status and challenges and developed recommendations for nmCRPC diagnosis and management in LATAM. The Americas Health Foundation (AHF) conducted a literature review and identified LATAM scientists and clinicians who have published in the field of PCa since 2012. The AHF convened a panel of 7 chosen experts urologists and medical oncologists from the region. The AHF developed specific questions relating to nmCRPC, which were answered by the experts prior to the multiday meeting. Each narrative was discussed and edited by the panel, through numerous rounds of discussion until a consensus was reached in a final manuscript. The panel proposes specific and realistic recommendations for improving access to diagnosis and management of PCa in LATAM. No treatment has yet shown improvement in overall survival; however, when including metastasis-free survival as an end point, second-generation antiandrogen drugs have emerged as effective treatment options and are currently included as first-line treatment. Although nmCRPC is a specific disease that represents a small percentage of patients with PCa, effective diagnostic and treatment strategies can contribute toward increasing quality of life and survival rates of patients with PCa in LATAM.

Efficacy and safety of darolutamide in Japanese patients with nonmetastatic castration-resistant prostate cancer: a sub-group analysis of the phase III ARAMIS trial

Background

Darolutamide, an oral androgen receptor inhibitor, has been approved for treating nonmetastatic castration-resistant prostate cancer (nmCRPC), based on significant improvements in metastasis-free survival (MFS) in the ARAMIS clinical trial. Efficacy and safety of darolutamide in Japanese patients are reported here.

Methods

In this randomized, double-blind, placebo-controlled phase III trial, 1509 patients with nmCRPC and prostate-specific antigen (PSA) doubling time ≤ 10 months were randomized 2:1 to darolutamide 600 mg twice daily or matched placebo while continuing androgen deprivation therapy. The primary endpoint was MFS.

Results

In Japan, 95 patients were enrolled and randomized to darolutamide (n = 62) or placebo (n = 33). At the primary analysis (cut-off date: September 3, 2018), after 20 primary end-point events had occurred, median MFS was not reached with darolutamide vs. 18.2 months with placebo (HR 0.28, 95% CI 0.11–0.70). Median OS was not reached due to limited numbers of events in both groups but favored darolutamide in the Japanese subgroup. Time to pain progression, time to PSA progression, and PSA response also favored darolutamide. Among Japanese patients randomized to darolutamide vs. placebo, incidences of treatment-emergent adverse events (TEAEs) were 85.5 vs. 63.6%, and incidences of treatment discontinuation due to TEAEs were 8.1 vs. 6.1%.

Conclusions

Efficacy outcomes favored darolutamide in Japanese patients with nmCRPC, supporting the clinical benefit of darolutamide in this patient population. Darolutamide was well tolerated; however, due to the small sample size, it is impossible to conclude with certainty whether differences in the safety profile exist between Japanese and overall ARAMIS populations.

Electronic supplementary material

The online version of this article (10.1007/s10147-020-01824-5) contains supplementary material, which is available to authorized users.

Novel therapies are changing treatment paradigms in metastatic prostate cancer

Metastatic castration-resistant prostate cancer (mCRPC) remains a terminal diagnosis with an aggressive disease course despite currently approved therapeutics. The recent successful development of poly ADP-ribose polymerase (PARP) inhibitors for patients with mCRPC and mutations in DNA damage repair genes has added to the treatment armamentarium and improved personalized treatments for prostate cancer. Other promising therapeutic agents currently in clinical development include the radiotherapeutic 177-lutetium-prostate-specific membrane antigen (PSMA)-617 targeting PSMA-expressing prostate cancer and combinations of immunotherapy with currently effective treatment options for prostate cancer. Herein, we have highlighted the progress in systemic treatments for mCRPC and the promising agents currently in ongoing clinical trials.

Predictors of survival, healthcare resource utilization, and healthcare costs in veterans with non-metastatic castration-resistant prostate cancer

OBJECTIVES

The objective of this study was to evaluate the association of prostate-specific antigen doubling time (PSADT) with metastasis-free survival (MFS) and overall survival (OS), and to describe healthcare resource utilization (HRU) and costs among patients with non-metastatic castrate-resistant prostate cancer (nmCRPC) in the Veterans Health Administration setting.

METHODS AND MATERIALS

Patients with nmCRPC were identified from the Veterans Health Administration electronic health record database (1/2007-8/2017). PSADT was categorized as <3 months, 3 to 9 months, 9 to 15 months, ≥15 months, and unknown. MFS and OS were assessed using multivariable Cox proportional hazards regression, including PSADT as a predictor. HRU and costs were described per-patient-per-year (PPPY).

RESULTS

Among 12,083 patients in the study, shorter PSADT was associated with shorter MFS and OS (PSADT <3 months vs. PSADT ≥15 months hazard ratio [HR] [95% confidence interval (CI)] = 0.307 [0.281, 0.335] and 0.371 [0.335, 0.410], respectively). Patients who developed metastasis had a 3-fold higher risk of death compared to those without metastasis (HR [95% CI] = 2.933 [2.763, 3.113]). Mean HRU increased following the onset of nmCRPC and metastatic castrate-resistant prostate cancer (mCRPC); mean inpatient stays more than doubled (0.2 vs. 0.5 and 0.6 vs. 2.8 PPPY, respectively). Similar increases in healthcare costs were observed; pharmacy costs more than tripled following nmCRPC ($2,074 vs. $6,839 PPPY). From nmCRPC to mCRPC, large increases were observed for inpatient costs ($7,257-$61,691), emergency room costs ($844-$1,958), and pharmacy costs ($4,115-$26,279) PPPY.

CONCLUSIONS

In Veterans with nmCRPC, shorter PSADT was significantly associated with shorter MFS and OS. Onset of nmCRPC and mCRPC was associated with substantial HRU and cost increases.

Recent developments in the treatment of non-metastatic castration resistant prostate cancer

Non-metastatic castration resistant prostate cancer (nmCRPC) is defined as a disease state withlack of radiographic evidence of metastatic disease, a confirmed rising PSA level on continuous ADT and maintaining a castrate level of testosterone following definitive therapy. Prior to the publication of PROSPER, SPARTAN and ARAMIS, no trials have demonstrated a clinical benefit for these patients. Recently enzalutamide, apalutamide, and darolutamide respectively, were tested in this disease setting with metastasis free survival (MFS) as the primary endpoint for each trial. In this review article, we define key terms related to the discussion of nmCRPC, examine the clinical trial design, and safety profile for each of these three key clinical trials and present updated overall survival (OS) results from these studies. Also we specifically discuss the key clinical trial results including the primary endpoint of MFS for each trial as well as quality of life effects of these three androgen receptor antagonists. Finally, this article examines the potential impact of molecular imaging testing on the applicability of these clinical trial results.