Management Decisions for Metastatic Castration-resistant Prostate Cancer in 2024

Section snippets

One size does not fit all: the importance of biomarkers

One of the themes from the review by Francini et al [1] that should be highlighted is the importance of biomarkers. Several new therapies are approved for biomarker-selected patients. When the right biomarker is present, patients have a better chance of deriving greater benefit from biomarker-directed therapy. In PROPEL, the hazard ratio (HR) for OS with addition of olaparib versus abiraterone alone for patients with a BRCA1 or BRCA2 alteration was 0.29 [2]. Many patients with tumors with high

Benefit and toxicity of prior therapy

Francini et al [1] lay out algorithms for treatment options on the basis of prior therapy received. In practice, when multiple treatment options exist, what is critical is not just what therapy was previously given but also how much benefit was received and what toxicities were endured. Eligibility criteria for the CARD trial included disease progression within 12 mo on a prior androgen receptor pathway inhibitor (ARPI), selecting for patients unlikely to receive a significant benefit from a

Radiation and radioligand therapy in mCRPC

ARPIs are relatively well tolerated and are thus ideal candidates for combination therapy. This is true for pharmacological therapy, with triplet therapy approved for metastatic HSPC and combination PARP inhibitor therapy approved for mCRPC. The ENZA-p trial showed that addition of adaptive-dosed ¹⁷⁷Lu-PSMA improved outcomes over enzalutamide alone [10]. Results from the phase 2 ARTO trial suggest that a similar strategy could be pursued with radiotherapy for patients with nonvisceral

Patients’ wishes and shared decision-making

Almost all patients value both quantity and quality of life, with individual patients putting more or less emphasis on each. Management decisions are made with collaboration between the patient and the treating physician. Knowledge of prior therapies and their benefit and toxicities and of molecular and clinical biomarkers can inform estimates of benefit from future therapies. Ultimately, a shared decision between the treating physician and the patient helps patients best accomplish their goals.