Identifying the Ideal Patient for Doublet versus triplet in mCSPC

In this segment, panelists discussed the clinical and genomic factors that guide escalation from doublet to triplet therapy in metastatic castration-sensitive prostate cancer (mCSPC). They agreed that while doublet therapy remains standard for most patients, select cases—particularly those with high-volume disease, visceral metastases (especially liver), de novo presentation, or specific genomic alterations such as PTEN or TP53 loss—may warrant triplet intensification. Emerging tools like PSA dynamics and genomic classifiers (e.g., Decipher) were cited as potential future guides for tailoring therapy. Panelists also emphasized the importance of assessing patient fitness and willingness for chemotherapy, noting that treatment choice should balance clinical benefit with patient preference. They highlighted that triplet therapy—typically ADT plus ARPI plus docetaxel—may offer greater benefit for aggressive disease biology, but patient selection remains nuanced. The discussion underscored the need for biomarkers and prospective data to better define who truly benefits from intensification.

Panelists noted that abiraterone, apalutamide, and enzalutamide demonstrate overall survival benefits, while darolutamide primarily delays progression. They discussed side-effect profiles and monitoring needs—highlighting the need for liver function monitoring and steroid co-administration with abiraterone—and emphasized that treatment selection often depends on balancing efficacy, toxicity, and clinician comfort.