Our standards of care reflect the importance of optimizing cancer treatments while taking both their efficacy and their associated complications into consideration. Advanced prostate cancer encompasses a wide range of disease, and we consider not only which therapies are appropriate at each stage but also the best timing for introducing these treatments for each individual patient.

We have level 1 evidence demonstrating that, for patients with metastatic hormone-sensitive prostate cancer, intensified treatment produces longer overall survival in clinical trials. Intensified treatment includes either docetaxel or novel androgen receptor (AR)–targeted agents (ie, abiraterone acetate, enzalutamide, or apalutamide) in addition to standard androgen deprivation therapy. Yet, real-world data suggest that there may be a relative underutilization of those combinations. In the analysis we presented at the recent 2021 American Society of Clinical Oncology Annual Meeting, data spanned from 2014 to 2019, but even in 2019 (ie, 1 year after the US Food and Drug Administration approval of abiraterone in this space and 3 years after the benefits of docetaxel emerged), more than half of patients with metastatic hormone-sensitive disease did not receive intensified treatment; those who did receive intensified treatment appeared to have shorter durations of treatment than were used in the respective registration trials.

Standards of care have also been evolving in the castration-resistant disease space. Among men with metastatic castration-resistant prostate cancer who were previously treated with docetaxel in the CARD trial, improved outcomes were reported with cabazitaxel after failure of a single AR-targeted therapy, as opposed to an alternative AR-targeted therapy. Yet, this is not always standard practice today. Safety and quality-of-life data also contribute to these standards. For instance, in patients with castration-resistant disease, antiresorptive agents can decrease the risk of symptomatic skeletal-related events in the setting of AR-targeted agents, chemotherapy, and even radionuclide agents such as radium-223. Thus, bone health is an important part of our standards.

A relatively new standard of care is the genetic profiling of patients with advanced prostate cancer. We now have 2 poly (ADP-ribose) polymerase inhibitors, rucaparib and olaparib, that are approved for select patients with metastatic castration-resistant prostate cancer (ie, those who have BRCA2 or other homologous DNA repair deficits, whether germline or somatic).

Finally, although there is no optimal one-size-fits-all treatment sequence for patients with advanced disease, it is my belief that we should try to treat patients with the available therapeutic modalities while they still have a good performance status. That means stopping a therapy that is not producing a clinical benefit and switching to another therapy. It also means being proactive in explaining to patients why it may be in their best interest to try therapies that do have side effects even while they are feeling pretty good.