Selective treatment de-escalation in advanced prostate cancer: have we come full circle?

Compelling evidence has solidified the notion of early treatment intensification in managing patients with metastatic hormone-sensitive prostate cancer (mHSPC). Landmark trials have provided Level 1 evidence for the survival benefits achieved by combining multiple agents. The efficacy of combined therapy relies not only on how treatment is intensified but also on how it is de-escalated. This underscores the importance of tailored treatment approaches, potentially involving a reduction in therapy for specific patients, to strike a balance between the benefits of hormonal treatment and its associated adverse effects. While de-escalation of therapy in mHSPC remains challenging due to limited evidence, it is recommended for elderly or frail patients, those with poor performance status, or experiencing significant toxicity. However, for patients with excellent prostate-specific antigen responses or favourable biomarkers, decisions should be personalised, weighing the potential benefits of continued treatment against the risk of long-term side effects, using risk stratification tools where appropriate.