Treatment decisions for metastatic castration-resistant prostate cancer (mCRPC) have evolved into a deeply personalized process that balances clinical efficacy with patient preferences and quality of life considerations. This individualized approach represents a significant shift in oncology care, emphasizing shared decision-making between patients and healthcare providers.
Patient-Centered Treatment Selection
The selection of mCRPC therapies is guided primarily by shared decision-making with patients, taking into account lifestyle preferences such as frequency of hospital visits and preference for oral medications that can be taken at home. Some patients may live close to treatment centers and feel comfortable with frequent visits for chemotherapy or intravenous therapies, while others prioritize independence and fewer hospital trips.
Treatment choices are shaped not only by clinical factors such as efficacy and safety but also by the patient's quality of life and logistical preferences. When deciding on endpoints, overall survival remains the most critical measure, but it's equally important to consider quality of life, as patients want to live longer while maintaining good function and avoiding excessive adverse effects or hospital time.
Genetic Profiling Guides Combination Therapy
Treatment decisions also take into account the specific genetic profile of the cancer, such as homologous recombination repair mutations, for which combination therapies may be preferred. Newly diagnosed patients may benefit most from combination therapies, as early treatment offers the best chance for disease control before progression leads to poorer outcomes.
Patients with homologous recombination repair (HRR) mutations often receive combinations such as androgen receptor pathway inhibitors (ARPIs) plus PARP inhibitors. For those progressing on ARPIs, treatment choices vary based on factors such as prostate-specific membrane antigen PSMA PET positivity, symptom severity, and bone involvement, including options such as chemotherapy, radium, or novel radioligand therapies.
Bone Health Management Priority
Bone health is a top priority due to the high risk of fractures and skeletal complications, which significantly affect quality of life and survival. All patients with metastatic mCRPC should receive bone-modifying agents such as bisphosphonates or denosumab, along with vitamin D and calcium supplementation, unless contraindicated.
Adverse Event Management Strategies
Adverse effects from cancer therapies are common and include anemia, nausea, fatigue, weight loss, and muscle wasting. Anemia frequently occurs with PARP inhibitors, requiring early dose adjustments or treatment breaks to maintain tolerability. Preventive anti-nausea medications are also important, particularly with agents such as olaparib.
Taking breaks is an accepted and important strategy when adverse effects impact quality of life. For patients responding well but experiencing significant toxicity, pausing therapy to recover and restarting at a reduced dose is a common practice. This flexible approach helps maintain treatment effectiveness while preserving well-being.
Comprehensive Supportive Care
Maintaining overall health through exercise, nutrition, and cardiovascular monitoring is vital, especially as patients live longer. Resistance training and physical activity can help preserve muscle mass and reduce fatigue, while tailored dietary guidance helps manage metabolic changes.
Cardiovascular health requires close attention, with routine cardiac evaluations such as echocardiograms and ECGs for those with symptoms or risk factors. Early recognition and proactive management of adverse effects enable patients to continue treatment safely and improve their quality of life during therapy for mCRPC.
The goal is to find a sustainable balance that maximizes survival and quality of life, emphasizing open communication and individualized care tailored to each patient's needs and values.
