Genomic Alterations to Guide Treatment Selection in Metastatic Prostate Cancer

Treatment options for men with metastatic prostate cancer have greatly expanded in the last decade. Androgen receptor pathway inhibitors, taxane cytotoxic therapy, poly(ADP-ribose) polymerase inhibitors, and radionuclide theranostics against prostate-specific membrane antigen have collectively contributed to incremental improvements in both quality and longevity of life for patients with metastatic castration-resistant prostate cancer (mCRPC). Despite these successes, few studies inform on optimal therapy selection and sequencing across this crowded treatment landscape. Genomic analysis of both tissue and liquid biopsy specimens shows promise in bridging this practice gap, with alterations in several key prostate cancer driver genes demonstrating clear associations with clinical outcomes, as well as informing use of novel precision medicine targeted therapies. In this review, we evaluate the current evidence of genomic alterations in various oncogenic signaling pathways as clinical biomarkers in mCRPC, focusing on correlative studies that analyzed outcomes based on findings in plasma cell-free DNA. We highlight the pitfalls of interpreting genomic findings in samples with substandard tumor content, and suggest pathologic and disease factors to consider when embarking upon tumor genotyping to guide treatment decisions in metastatic prostate cancer. As access to life-prolonging therapies improves, and barriers to cost-effective genotyping and reliable data interpretation are overcome, we anticipate that predictive and prognostic biomarkers that inform on disease biology, drug sensitivity, and therapy resistance will inevitably be integrated into the routine care of patients with metastatic prostate cancer.