2. UroToday Home
  3. Video Lectures
  4. Advanced Prostate Cancer

A SEER Database Analysis of Real-World Survival Trends in Metastatic Prostate Cancer - Pedro Barata

November 6, 2025

Neeraj Agarwal and Pedro Barata discuss SEER database analysis of survival outcomes in over 42,000 patients with metastatic prostate cancer from 2010 to 2021. The data demonstrates continuous improvement in median overall survival to approximately five years, matching the introduction of life-prolonging therapies. However, Dr. Barata highlights that real-world survival improvements remain modest compared to clinical trial results due to significant treatment attrition, where approximately 15-20% of patients never receive anticancer therapy and roughly half are lost between each subsequent treatment line. Only 20-25% of patients reach third-line therapy. This attrition provides strong rationale for combination therapy approaches, ensuring patients receive multiple therapeutic modalities upfront rather than sequencing treatments they may never reach. The discussion emphasizes that real-world practice differs from clinical trials, with less rigorous imaging protocols and greater reliance on PSA monitoring.

Biographies:

Pedro C. Barata, MD, MSc, FACP, Miggo Family Chair in Cancer Research, Co-Leader Genitourinary (GU) Disease Team, Director of GU Medical Oncology Research Program, University Hospitals Seidman Cancer Center, Associate Professor of Medicine, Case Western Reserve University, Case Comprehensive Cancer Center, Cleveland, OH

Neeraj Agarwal, MD, FASCO, Professor, Presidential Endowed Chair of Cancer Research, Director GU Program and the Center of Investigational Therapeutics (CIT), Huntsman Cancer Institute, University of Utah, Salt Lake City, UT

Related Content:

ESMO 2025: Survival Outcomes in Metastatic Prostate Cancer: An analysis of the US population-based SEER database (2010-2021)

ESMO 2025: Real-world Overall Survival in US-Based Patients with Metastatic Hormone-Sensitive Prostate Cancer

ASCO GU 2025: Survival Outcomes of Patients with Metastatic Castration-Resistant Prostate Cancer (mCRPC) Receiving Lutetium-177-PSMA-617 (Lu) Based on Line of Therapy

ASCO 2025: Real-World Patient Characteristics, Treatment Patterns, and Overall Survival in Metastatic Hormone-Sensitive Prostate Cancer: Insights by PTEN Status
Read the Full Video Transcript

Neeraj Agarwal: It's such a pleasure and an honor to have Dr. Pedro Barata on this UroToday video episode. Dr. Barata is an Associate Professor of Medicine and Oncology and an Endowed Chair of Clinical Research at Case Western Reserve University/University Hospitals in Cleveland. What an accomplishment so early in your career. Thank you for spending time with us today.

Pedro Barata: Neeraj, you're too kind. Thank you so much for the opportunity to be here with you and highlight the presentation we had at ESMO.

Neeraj Agarwal: So Pedro, you presented really telling data from the real world from literally thousands of patients with metastatic castration-resistant prostate cancer on their survival and other aspects of their care. So I'd like to first focus on the results of those studies. So could you tell us more about the study, the results, and then we can talk about the implications of these findings?

Pedro Barata: Right. No, great question. And really, what triggered... so we looked at, as you said, survival outcomes for patients with metastatic prostate cancer. And what really triggered that project was the fact that the landscape has changed so dramatically within the last 10 to 15 years, perhaps, that we know that what patients are doing now is not the same as what they were doing in 2015, 2010, et cetera. So we wanted to document that and provide that data out there to have it in the public domain so we can use it as a benchmark as we keep evolving with novel therapeutics, and I'm sure we're going to talk about that in a minute.

So we used the SEER database, which covers almost 50% of the patients diagnosed with metastatic prostate cancer in the United States. So we're really talking about over 42,000 patients in that database, 2010 to—

Neeraj Agarwal: So you're talking about 42,000 patients?

Pedro Barata: Yes.

Neeraj Agarwal: I just want to make sure we put it on record.

Pedro Barata: Right.

Neeraj Agarwal: This is a massive number of patients.

Pedro Barata: Yes. It's a large number of patients, all with metastatic disease. And basically between 2010 and 2021, and actually, more than half of the patients were from 2017 to 2021. And the reason why we stopped four years ago or so is to get enough follow-up, right? Fortunately, this is a disease in the metastatic setting where median overall survival is measured in many years. So we needed enough follow-up to get median overall survival.

So in short, without any suspense, we basically show the Kaplan-Meier curves there and what we see is what we already know, right? The median overall survival has been getting better with more contemporaneous populations, which basically matches the introduction of life-prolonging therapies.

So we usually quote or used to quote a five-year overall survival for men with metastatic prostate cancer of about a third of the patients getting there—we're getting better. So you beautifully see, as time goes by, patients are living longer. So you don't see big leaps, if you will, but what you see is a continuous improvement in how long patients are expected to live with their disease and it matches the introduction of therapies that are now available that we currently use, and that will continue to be the case.

Neeraj Agarwal: But I did not find the increase in survival to be what we expected it to be. If you look at six life-prolonging therapies with different mechanisms of action, starting with docetaxel in 2004, but then in the metastatic hormone-sensitive setting, we got docetaxel, then abiraterone, enzalutamide, or all the ARPIs, I would say, radium-223, sipuleucel-T, and then, of course, lutetium-177 treatment and then PARP inhibitors, pembrolizumab for the TMB-high, MSI-high patients. If you look at all these therapies put together and, of course, with bone-modifying agents...

Pedro Barata: Right.

Neeraj Agarwal: ...I was hoping and expecting to see a much larger improvement in overall survival. So what do you think is going on here?

Pedro Barata: Yeah. So fantastic comment, Neeraj, and I agree with you. And it's interesting how we look at that and this is real-world data. And you look at the trial data where we have a very selective group of individuals where we're testing an intervention, whatever that intervention might be. And in reality, what's happening is this big treatment attrition where, in fact, we lose about half of the patient population. So one way to think of this, if we think of 100 people or 100% of folks who are diagnosed with metastatic disease, we actually don't treat 100% of them in reality. We have a number of patients, which might be 15 to 20% of them, who are too sick, very frail, dealing with other problems in their health. They're going into comfort care or hospice.

Neeraj Agarwal: So they don't get treatment.

Pedro Barata: They never get treatment.

Neeraj Agarwal: So how about those 80 patients who get treated?

Pedro Barata: Right.

Neeraj Agarwal: What happens to them?

Pedro Barata: So if you think of the patients who end up getting anticancer treatment, whether it's ADT or ADT plus something else, one way to think about it, you lose about half of them every time you move from one line of therapy to the next, right? So if you think of 100% of them, only half or so will end up getting a second line and only about 20 to 25% end up getting a third line and so on.

So what that means—this really has been very consistent. You've shown that data. We've been seeing that data from different databases. We've seen data from the VA. We've seen data from the Medicare system, Flatiron, several databases, always showing the same thing. To me, that's a critical point because every time we talk about sequencing, it always starts with the assumption that we are going to be getting A, B, C, D, E.

Neeraj Agarwal: To everyone.

Pedro Barata: Right. And that's not true. And so one example is the study you were involved with on PARP inhibitors, the BRCAAway trial that we were talking about earlier, where when you look at A plus B versus A followed by B or B followed by A, you see that, to me, one of the significant points of this study is how many people did not get B or A in the other arms when you're sequencing them, which means a lot of times, even if there's not a synergistic effect between the two interventions, just offering them upfront guarantees that the patient or the disease is being exposed to the different therapies.

Neeraj Agarwal: So great implication of these data that survival outcomes are not keeping up in the real world with the clinical trial outcome data.

Pedro Barata: Right.

Neeraj Agarwal: So clinical trial survival results are simply not there at the community level, at the real-world level. We are not able to translate those data in the real world. And there could be many reasons, increased frailty of patients, but also high attrition from first-line to second-line to third-line therapy. And you are saying that's why combination therapy works, because patients get to get both therapies at one go rather than having to wait for sequencing.

Pedro Barata: Right. I don't think it's a coincidence. I mean, there's a lot to say about treatment strategies, combination strategies for metastatic prostate cancer. I don't think it's a coincidence. We've seen actually several combinations. I mean, we talked about PARP inhibitor-ARPI as one example. We talked about ARPI with radium-223 as another example. We're really excelling and doing a lot better than we had with sequencing those therapies because they were available and around, but we have other combinations. We have combined different ARPIs, as we know. We didn't see a difference in overall survival, but certainly, the tumor control is also longer.

So the thought process around how patients get therapies is a truly relevant one, right? And I would also say that in real life, we don't necessarily practice the same way we do on studies. So we're not as rigorous around getting scans on a regularly consistent basis, for example. We maybe rely a bit more on PSA in real life. And as we know, many tumors progress without having rising PSA. We've seen that with data from the CAPItello trial—

Neeraj Agarwal: CAPItello trial.

Pedro Barata: —with capivasertib in the CAPItello trial.

Neeraj Agarwal: About half of the patients had disease progression without PSA progression.

Pedro Barata: Exactly.

Neeraj Agarwal: And in the community or in the real world—even in my clinic, sometimes, I don't do scans for a year if PSA is going down nicely. So again, that's a fantastic point.

So just summarizing the study and the lessons, what are the main lessons? If I want you to give us two lessons from your study and this discussion today...

Pedro Barata: Sure.

Neeraj Agarwal: ...what are those for our audience?

Pedro Barata: Yeah, it's a great question. So the life expectancy of men with metastatic prostate cancer is measured in years. We are making progress. So those patients are now expected to live about five years or so altogether, without getting into the details about who they are. The strides in improvement of life expectancy match the introduction of different life-prolonging therapies with different mechanisms of action. And so, continuing the effort that we're putting into trying to develop efficacious therapeutics in the landscape of metastatic disease will likely continue, and outcomes will continue to get better. Patients will continue to live longer, hopefully, and that's the goal. So that's really what we take out of that.

Neeraj Agarwal: And also we should be making sure that patients are able to get subsequent lines of therapies. And if they cannot, maybe combination therapy approaches if they are available.

Pedro Barata: Right. It certainly provides the rationale to explore thoughtful combination strategies because for a lot of the patients, the first attempt to treat them, in many cases, is actually their last attempt to treat them.

Neeraj Agarwal: That's a great way to finish it. Thank you very much.

Pedro Barata: Thank you so much, Neeraj, for having me.