Special Report: New strategies emerge for metastatic prostate cancer

In this Special Report from Urology Times®, Michael S. Cookson, MD, MMHC, FACS, and Kelly L. Stratton, MD, FACS, address the increasing prevalence of de novo metastatic hormone-sensitive prostate cancer and the treatment landscape for men presenting with this condition. Cookson notes that over the past 5 or more years, there has been a noticeable rise in diagnoses of advanced prostate cancer. Several factors contribute to this trend, including reduced screening participation during the COVID-19 pandemic and limited health care access, particularly in rural regions like Oklahoma. As a result, many cases are being identified later than optimal. Although screening aims to detect high-risk cases early for potential cure, many patients in the US—though not as many as in Europe—still present with metastatic disease at diagnosis.

Stratton outlines the modern treatment framework for such cases, beginning with androgen deprivation therapy (ADT) as the foundational approach. ADT can be delivered via long-acting injections like leuprolide or oral agents like relugolix (Orgovyx), both of which reduce testosterone levels. Beyond ADT, treatment can be escalated based on disease burden and patient factors. For widespread metastatic disease, combination therapies including ADT with anti-androgens such as abiraterone (Zytiga) or enzalutamide (Xtandi) are standard. For patients with high-volume disease who are medically fit, triplet therapy that incorporates chemotherapy (e.g., docetaxel) alongside hormonal agents is an option.

Cookson emphasizes the significant improvement in outcomes compared to earlier eras when only monotherapy was available, with limited efficacy. Now, patients can experience prolonged remission and even long-term disease control. Stratton adds that for those progressing after first-line therapies, additional options such as immunotherapy (eg, sipuleucel-T [Provenge]), radiopharmaceuticals like radium-223 (Xofigo), and prostate-specific membrane antigen-targeted therapies (eg, lutetium) offer further lines of treatment, allowing care to be individualized and extended over time.

Our panelists:

Michael S. Cookson, MD, MMHC, FACS, is a professor and the Donald D. Albers Endowed Chair in Urology at the University of Oklahoma Health Sciences Center in Oklahoma City. He is also a Co–Editor in Chief for Urology Times®.

Kelly L. Stratton, MD, FACS, is an assistant professor of urologic oncology and an adjunct associate professor of medicine at the University of Oklahoma (OU) College of Medicine and the chair of urologic oncology at the OU Stephenson Cancer Center in Oklahoma City. He is also a member of the Urology Times Editorial Council.