Expert Opinion on Current Treatment Alternatives for Patients With Prostate Cancer Progressing From the Metastatic Hormone-Sensitive Stage to the Castration-Resistant Stage After Receiving Early Treatment Intensification

Abstract

For patients with castration-sensitive prostate cancer (mCSPC), treatment intensification with androgen deprivation therapy (ADT) plus new androgen receptor pathway inhibitors (ARPIs) has opened a scenario where no guidance exists to indicate the best treatment after progression to metastatic castration-resistant prostate cancer (mCRPC). Clinical decision-making has become even more complex, with the proven benefit for selected patients of triplet therapy with abiraterone or darolutamide added to the double combination therapy of ADT plus docetaxel. The profile of patients for whom triple therapy would be more beneficial is being defined beyond metastatic disease presentation and volume (eg, poor prognosis features). In October 2023 and October 2024, a panel of eight Spanish medical oncologists with expertise in the management of prostate cancer met to discuss the challenges in treating mCRPC. The scientific evidence was reviewed during this meeting, knowledge and experience were shared, and controversies were discussed until a consensus was reached. This information was collected and turned into a manuscript aimed at helping clinicians determine the optimal treatment sequence after disease progression based on scientific evidence and experts’ opinions and consensus. To this end, the profile of mCSPC patients who may have received double or triplet therapy is analyzed, current treatment options are reviewed, and treatment algorithms are proposed. New and expected advancements in this field are also presented.