How We Treat Metastatic Castration-Sensitive Prostate Cancer.

Area of Science:

• Oncology
• Urology
• Medical Imaging

Background:

• Metastatic castration-sensitive prostate cancer (mCSPC) treatment has evolved significantly.
• Heterogeneity in mCSPC necessitates refined risk stratification and treatment selection.
• Concerns exist regarding potential overtreatment in mCSPC.

Purpose of the Study:

• Review clinical trials on intensified triplet regimens for mCSPC.
• Provide recommendations for selecting patients for novel combination therapies.
• Discuss a PSA-adapted approach for low-volume mCSPC identified by PET imaging.
• Explore treatment de-escalation strategies and metastasis-directed therapy.

Main Methods:

• Review of clinical trials on intensified triplet regimens (androgen deprivation therapy, second-generation androgen receptor signaling inhibitors, docetaxel).
• Case report-based discussion of clinical practice.
• Analysis of PET imaging in identifying low-volume mCSPC with nodal metastases.
• Discussion of ongoing clinical trials and local treatment modalities.

Main Results:

• Intensified triplet regimens show promise but require careful patient selection.
• PET imaging identifies a subset of low-volume mCSPC not detectable by RECIST criteria.
• A PSA-adapted approach is proposed for non-measurable low-volume mCSPC.
• Treatment de-escalation and metastasis-directed therapy are emerging strategies.

Conclusions:

• Optimizing first-line treatment selection is crucial for mCSPC management.
• Novel diagnostic and therapeutic strategies are refining mCSPC care.
• Personalized approaches, including metastasis-directed therapy, are key for improving outcomes in mCSPC.