Optimizing Care for Patients With Metastatic Castration-Resistant Prostate Cancer

The therapeutic landscape of metastatic castration-resistant prostate cancer (mCRPC) has evolved substantially over the past decade, with androgen receptor pathway inhibitors, taxanes, poly (ADP-ribose) polymerase (PARP) inhibitors, radioisotopes, bone-protecting agents, and emerging targeted therapies improving survival for patients. At the same time, earlier treatment intensification in the hormone-sensitive setting has resulted in heterogeneous clinical presentations at the onset of castration resistance, adding complexity to treatment sequencing and clinical decision making. Here, we propose a pragmatic, patient-centered framework to help guide the management of mCRPC by integrating clinical features, molecular profiling, imaging findings, and supportive care considerations. Confirmation of castration resistance remains a critical first step and requires documented biochemical or radiographic progression in the setting of castrate testosterone levels. Treatment selection should consider prior systemic therapies, disease burden and tempo, symptom profile, comorbidities, and frailty. Molecular characterization, including evaluation for homologous recombination repair alterations and mismatch repair deficiency, is highly important for identifying candidates for PARP inhibitors or immune checkpoint blockade and other emerging biomarker-driven targeted strategies. Prostate-specific membrane antigen (PSMA)-targeted radioligand therapy has emerged as a key treatment. PSMA-positron emission tomography-based selection, incorporating assessment of uptake intensity, tumor heterogeneity, and total tumor volume, may help identify patients who are most likely to benefit from this treatment. Clinical factors such as liver metastases and limited prior response to androgen receptor-directed therapy have been associated with less favorable outcomes. Early on-treatment assessment using prostate-specific antigen response and PSMA-based imaging may support adaptive treatment strategies and earlier recognition of resistance. Given the high prevalence of bone metastases, bone-protecting agents should be considered to reduce skeletal-related events. Early palliative care (EPC) is now widely recognized as a concurrent, patient-centered intervention that improves quality of life, symptom burden, coping, and satisfaction across advanced cancers. Prostate cancer represents an especially compelling setting for EPC because of prolonged advanced disease courses, cumulative symptom burden, repeated treatment transitions, and persistent unmet supportive needs.