Factors to Guide Treatment Selection for Hormone-Sensitive Metastatic Prostate Cancer

For decades, the mainstay of treatment for metastatic hormone-sensitive prostate cancer has been androgen deprivation therapy. In recent years, 4 systemic therapies-docetaxel, abiraterone, enzalutamide, and apalutamide-have improved overall survival for men with metastatic hormone-sensitive prostate cancer when combined with androgen deprivation therapy, raising the question of which treatment to choose. The role for metastasis-directed therapy with surgery or radiation among these new treatments has also yet to be defined. Thus, several factors have come into play to guide treatment selection, including disease characteristics, age, fitness, and comorbidities of the patient, potential adverse effects of therapies, and health system considerations such as access to care and financial toxicity. Careful and shared decision making between patient and provider is critical. Future directions aimed at refining our treatment selection include researching the role of novel molecular imaging techniques, biomarkers predicting therapy response, sequencing and combining therapies, and understanding the long-term and late effects of these treatments.