- Design
- Meta-analysis of 17 retrospective real-world studies
- Population
- 18,626 men with metastatic hormone-sensitive prostate cancer
- Primary outcome
- Overall survival, PSA response, time to CRPC, discontinuation
- Effect
- Apalutamide vs abiraterone OS HR 1.27 (1.09 to 1.47); discontinuation for AEs lower with abiraterone (OR 0.56)
This meta-analysis pooled 17 retrospective real-world studies of 18,626 men with metastatic hormone-sensitive prostate cancer treated with ADT plus apalutamide, abiraterone or enzalutamide. No randomised trial compares the three directly.
Apalutamide doublets were associated with better overall survival than abiraterone (reported HR 1.27, 95% CI 1.09 to 1.47), deeper PSA responses, and longer time to castration resistance. Apalutamide also had higher PSA90 response than enzalutamide. Discontinuation for adverse events was lower with abiraterone than apalutamide. Abiraterone and enzalutamide looked similar.
In retrospective data, the choice of drug reflects the patient, the era and the payer. These results support choosing on comorbidity, interactions and cost rather than switching wholesale.
- Offer an ARPI doublet (or triplet where indicated) to every fit man with mHSPC.
- Choose the agent on comorbidity: abiraterone needs steroid and liver and cardiac monitoring; enzalutamide and apalutamide carry falls and rash risks.
- Check drug interactions before starting.
- In India, cost and generic availability of abiraterone often decide; that remains a reasonable choice.
Why it matters
Without head-to-head trials, clinicians are choosing between agents on limited data.
Don't overread it
Retrospective real-world studies; the differences are associations, not proof one drug is better.
The statistics, in plain English
Pooling retrospective studies adds numbers but not randomisation. A survival difference of this size between drugs is plausible for confounding alone.
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