Balancing Efficacy and Cardiotoxicity in Prostate Cancer Therapy: A Call for Precision in Treatment Strategies

High-risk, potentially lethal prostate cancer (PCa) requires systemic androgen deprivation therapy (ADT), with doublet therapy offering superior anticancer effects in comparison to monotherapy, and triplet therapy being more effective than doublet. However, nothing comes without a cost. In the review of such combination therapies by Aziz et al [1] in this issue of European Urology, the authors endeavour to add granularity to the existing evidence, showing that a significant cost on the final bill is a higher risk of cardiovascular toxicity. It is well established that cardiovascular disease (CVD) is a leading cause of death among PCa patients [2], and men with pre-existing CVD fare worse: 18% of patients with baseline CVD in the HERO trial experienced a major adverse cardiac event within 1 yr of starting leuprolide [3]. The RADICAL-PC study demonstrated that in the real world, 99% of men harbour at least one, and 51% more than two, poorly controlled cardiovascular (CV) risk factors [4]. Should we be doing more to address this issue? Aziz et al [1] add weight to the evidence that we should, but there are caveats in interpretation of the data presented.