Historically, in threatening cancers with limited effective treatment options, addressing the cancer was synonymous with treating the patient because the patient's dominant symptoms were related to the complications of the cancer. The initial studies of chemotherapy and second-generation hormonal therapy showed that controlling the cancer improved the quality and length of survival.

As more treatment options for prostate cancer have become available, patients have been living longer, allowing for a greater focus on vulnerable older patients who may experience treatment-related side effects that could erode their quality of life. Therefore, in patients with an expected long survival, focusing on the cancer exclusively is not synonymous with good care, particularly when accounting for patient expectations. As the fear of imminent mortality diminishes and the management of prostate cancer becomes viewed as a longer-term endeavor, and as negative treatment-related side effects mount, accounting for both the quality and length of survival is required to provide the best care. 

In addition to therapeutic efficacy, the survival of patients with mCRPC is impacted by initial stage migration and the earlier detection of the progression. The earlier initial diagnosis and the detection of progression spur the desire to initiate a new treatment earlier. We, as treating oncologists, emphasize the traditional measures of success that are reflected in the efficacy of therapeutics. The need to develop a comprehensive treatment strategy founded on the understanding of the interaction between agents, patient vulnerabilities, and expectations will be required to build on current therapeutic successes. Progression-free survival is a strong indicator of a drug's efficacy, while overall survival is a strong indicator of a drug’s efficacy as part of the whole approach to treatment. These complementary concepts must both be considered to arrive at an optimal therapeutic strategy.  

Moving the “goal post" by stage, there is a risk of exposing people to continuous treatment without proportional gain. As overall survival is lengthened, quality of survival becomes a greater consideration. The more sensitive diagnostics that are introduced clinically may prompt earlier treatment, but whether this will translate into proportional gain (ie, lengthening survival while maintaining a good quality of life) is not yet known.

The care of patients with prostate cancer has evolved significantly in recent years, with the introduction of life-prolonging treatments. Incorporating a patient's values and preferences in their treatment plan will need to be accounted for. We, as oncologists, largely adhere to “traditional oncology-based" outcomes that will need to be adjusted.

Data presented at the 2022 Genitourinary Cancers Symposium by George et al demonstrate the importance of patients' expectations and preferences, as well as understanding what matters most to them, when considering treatment options for mCRPC (abstract 80). This abstract emphasizes the need to consider quality of life as it is defined by the patient in assigning benefits of therapy and the importance of inaugurating a change in the way we design studies to incorporate patient views and expectations more fully in our measures of success.