Abiraterone and Enzalutamide Show Comparable Outcomes in US Veterans With Metastatic Prostate Cancer

Key Clinical Summary

• A VA cohort study of 1569 US veterans found no significant difference in survival or tumor growth between abiraterone and enzalutamide in metastatic hormone-sensitive prostate cancer (mHSPC).
• Comparable results were seen across racial groups, including African American and White veterans.
• Findings suggest therapy choice may depend more on cost, comorbidities, and drug interactions than efficacy.

A large cohort study published by the US Veterans Affairs Health Care System found that abiraterone and enzalutamide provide similar clinical outcomes for patients with metastatic hormone-sensitive prostate cancer (mHSPC). Researchers analyzed data from more than 1500 veterans treated between 2017 and 2023, providing one of the most comprehensive real-world comparisons of these two androgen receptor pathway inhibitors.

Study Findings

In the analysis, 1258 veterans received abiraterone and 311 received enzalutamide. The median age was 73 years, and 25% of participants were African American. Median overall survival (OS) was identical for both drugs at 36.2 months. Tumor growth, measured via prostate-specific antigen (PSA)–based growth rate (“g-rate”), also showed no difference between the two therapies.

Inverse probability weighting and 1:1 exact matching analyses confirmed the equivalence, adjusting for age, race, comorbidities, and tumor features. Among African American veterans, OS remained comparable—39.7 months for abiraterone versus 40.3 months for enzalutamide (HR, 0.98; 95% CI, 0.72–1.34; P = .90). Similar results were observed in patients with cardiovascular disease and across subgroups defined by Gleason score and PSA level.

Lead investigators emphasized that this is the first large-scale, practice-based comparison of these agents for mHSPC in a diverse veteran population. The findings suggest that despite differences in mechanism and cost, both therapies provide equivalent disease control and survival benefits.

Clinical Implications

These findings have practical importance for clinicians treating veterans with mHSPC. Given the comparable survival outcomes, selection between abiraterone and enzalutamide can be guided by patient comorbidities, adverse effect profiles, drug–drug interactions, and financial considerations.

Abiraterone, now available as a generic, offers a cost-effective option without compromising efficacy. For patients with cardiovascular comorbidities or hepatic concerns, clinicians may weigh potential risks associated with each agent. The study also reinforces the VA system’s role in delivering equitable cancer care—highlighting similar outcomes across racial groups.

With both therapies performing equally well, optimizing sequencing and supportive care may become a greater focus in treatment planning.

Conclusion

Among US veterans with metastatic hormone-sensitive prostate cancer, abiraterone and enzalutamide achieved similar tumor growth rates and overall survival across all subgroups. Clinicians may base treatment choice on cost, toxicity, and patient preference rather than efficacy differences. These results underscore the importance of individualized, value-based prostate cancer care in the veteran population.

Reference

Leuva H, Zhou M, Teply BA, et al. Abiraterone vs enzalutamide among US veterans with metastatic hormone-sensitive prostate cancer. JAMA Netw Open. 2025;8(11):e2540730. Published 2025 Nov 3. doi:10.1001/jamanetworkopen.2025.40730