Treatment Intensification With Novel Hormonal Therapy in Castration-Sensitive Prostate Cancer: Patient Identification and Clinical Rationale

The clinical rationale for treatment of castration-sensitive prostate cancer (CSPC) with novel hormonal therapy (NHT) or androgen receptor pathway inhibitor is reviewed. A PubMed search was conducted to identify relevant publications Level 1 clinical evidence demonstrated that intensification of androgen deprivation therapy (ADT) with NHT prolongs life and improves or maintains quality of life in patients with metastatic CSPC (mCSPC). Despite these results, real-world evidence demonstrated that 47%-88% of patients with mCSPC are treated with single agent ADT. Possible explanations for the underutilization of NHTs include patient characteristics, misperceptions about the overall survival benefit, lack of physician and patient awareness of the magnitude of clinical trial results, physician bias, safety concerns, misconceptions about the magnitude of prostate-specific antigen response needed for patient improvement, and barriers to NHT access. For patients with biochemical recurrence and no evidence of metastatic disease, limited clinical data exist with no consensus on an effective treatment strategy. Therefore, treatment strategies are developed using patient risk stratification according to clinicopathological characteristics, genomics, and next-generation imaging. Patients with high-risk biochemical recurrence may benefit from the early initiation of NHT based on outcomes from the phase III EMBARK trial. Lifestyle management is also an important aspect of treatment for CSPC, helping to mitigate the side effects of hormonal treatment and ensuring patients can maintain treatment while optimizing quality of life. In conclusion, to improve outcomes in patients with mCSPC, it is important to implement solutions addressing the barriers to underutilization of treatment intensification.