Approaching Patients with Metastatic Prostate Cancer

When managing patients with metastatic prostate cancer, it is important to consider factors such as PSA levels, extra prostatic extension, and the Gleason score to determine the risk category. For patients without metastatic disease, adjuvant abiraterone and prednisone may be considered. However, for patients with metastatic disease, the first step is to determine if it is castrate sensitive or castrate resistant and if it is high or low volume. It is important to conduct genetic testing for homologous recombination repair gene mutations. In the case of low volume castrate sensitive metastatic prostate cancer, options such as chemotherapy with docetaxel, abiraterone plus ADT, enzalutamide plus ADT, or apalutamide plus ADT can be considered. However, the choice of treatment depends on factors such as cost, experience, and access to drugs. For high volume castrate sensitive metastatic prostate cancer, triplet therapy with docetaxel, abiraterone, and prednisone or darolutamide plus docetaxel and ADT may be preferred.