Controversies in metastatic hormone-sensitive prostate cancer

Abstract

Metastatic hormone-sensitive prostate cancer (mHSPC) is an incurable phase of prostate cancer. Diagnostic tools and management strategies for this complex disease are expanding. Despite these advances, more therapies may not be the optimal approach for all patients. This review explores four major controversies surrounding mHSPC management-the role of prostate-specific membrane antigen positron emission tomography scans as diagnostic imaging, triplet therapy (androgen deprivation therapy, androgen receptor pathway inhibitor, and docetaxel chemotherapy), radiation to the prostate and/or oligo-metastases, and bone modifying agents. Critical evaluation of the data emphasizes the need for further work to determine which subgroups of patients with mHSPC benefit from each treatment. With a deeper understanding of these current issues, this review seeks to guide clinicians to refine their clinical practice to help patients achieve their best quantity and quality of life.

Keywords: PSMA PET; bone modifying agent; controversies; metastatic hormone‐sensitive prostate cancer; radiation; triplet therapy.

FIGURE 1

Natural history of prostate cancer based on PCWG2 and controversies in management of mHSPC. mHSPC indicates metastatic hormone‐sensitive prostate cancer; PCWG2, Prostate Cancer Working Group 2.

FIGURE 2

Discordant findings on PSMA PET versus technetium‐99m bone scan in a patient with de novo metastatic hormone sensitive prostate cancer. (A) Single bone lesion at the right L4 pedicle was PSMA‐avid on axial (left) and coronal (right) views. (B) Techneitum‐99m bone scan without uptake in the right L4 pedicle. How do you manage these discordant imaging findings? PET indicates positron emission tomography; PSMA, prostate‐specific membrane antigen.