Phillip Koo:

Oftentimes we hear about ARPIs. We know there are four, as you mentioned. It's easy for us to want to sort of group them all together or think, oh, one, they're all the same. And sometimes we try to compare different trials. What advice do you have for the listener on with regards to sort the scientific method and what we might think of just from a conventional wisdom perspective?

Zachary Klaassen: 

Yeah, it's a great question, Phil. I'm going to take a step back even further. I think we know in 2025 that if you have metastatic hormone-sensitive prostate cancer, aside from the odd patient, everybody should be getting ADT, which is the backbone, plus one of these four options. Unfortunately, in this country, we still see a lot of ADT monotherapy, and this is just treatment. This is not intensification; this is not standard of care. 

So, unless there's some really random reason why not to, everybody should be getting one of these four. So, if we take that as this is our goal, as patient education, as physician education, if you're on one of these four, it's way better than having ADT by itself.

So having said that, to your point, you know, these all work very well, and they all show improvement versus ADT alone. And so, it becomes sort of a bit of a nuance in terms of, you know, some work a little bit better in patients that have a history of seizures. Some work a little bit better in terms of other medications that somebody may be taking, such as cholesterol medicines or blood thinners and stuff like that. 

Some is just better covered by insurance companies. And so, I think there's a lot of aspects that go into it. Some of it is provider dependent. Maybe they like one a little bit better than the other. That's fine. Some of is based on what's covered by insurance. And some of it's based on what's cover in terms of what the other medications the patient's taking. So, the take-home here is they all work very well. Everybody that has this disease state should be on it, at least a combination therapy.

To your point of comparing these trials, we…. From a scientific standpoint, we shouldn't compare these trials. We do in these conversations because this is what we have in the clinic, but there's populations, they're similar populations, but they're not perfect in terms of comparing head-to-head. 

There's never been a head-to-head of ARPI number one versus number two or number two versus number three. We have the individual trials. And so, from a scientific standpoint, not kosher to necessarily compare them, but when we're looking at the clinical data, we're looking at the patients in front of us, we certainly do that all the time in terms of how we're making treatment decisions.

Phillip Koo: 

Great, you know, I agree it's nuanced and I think for the listeners out there, every time you hear these types of headlines and you hear these new options, it doesn't mean you have to change, it's just sort of new information that helps us make better informed decisions. So, that was a great summary.

Zachary Klaassen: 

I'll just chip in really quick, so the patients know the name. So, this is darolutamide, this is apalutamide, enzalutamide, and abiraterone. So those are the four that they should be considering if they're looking at treatment intensification.