The first 60 days: Metastatic castration-resistant prostate cancer
Metastatic castration-resistant prostate cancer is disease that grows despite castrate testosterone. Sequenced treatments now include androgen receptor inhibitors, docetaxel and cabazitaxel, PARP inhibitors for men with BRCA-type mutations, the radioligand 177Lu-PSMA-617 and radium-223 for bone-predominant disease. Below, week by week, is what OnCo's record of Metastatic castration-resistant prostate cancer says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- RadiologistNamed in the standard of care for: After an androgen receptor pathway inhibitor, After docetaxel, Phase 3 options.
- Medical oncologistNamed in the standard of care for: First line, androgen receptor pathway inhibitor-naive, After an androgen receptor pathway inhibitor, After docetaxel, Bone health and 1 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: After an androgen receptor pathway inhibitor, After docetaxel, Bone health, Phase 3 options.
- Palliative and supportive care teamNamed in the standard of care for: Bone health.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Abiraterone or enzalutamide; add olaparib, talazoparib or niraparib for HRR-mutant, above all BRCA-mutant, disease (PROpel, TALAPRO-2, MAGNITUDE).
Docetaxel; olaparib or rucaparib for BRCA-mutant disease (PROfound); 177Lu-PSMA-617 for PSMA-positive disease before chemotherapy (PSMAfore); pembrolizumab for mismatch repair-deficient tumours.
177Lu-PSMA-617 (VISION), cabazitaxel, radium-223 for symptomatic bone-only disease (ALSYMPCA), or a PARP inhibitor if not yet used.
Denosumab or zoledronic acid to prevent skeletal events, with calcium and vitamin D; palliative radiotherapy to painful metastases.
Actinium-225 PSMA radioligands, the STEAP1 T-cell engager xaluritamig, the EZH2 inhibitor mevrometostat and 177Lu-PSMA-I&T within trials.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Tumour and germline HRR genes, PSMA PET uptake and FDG discordance, Mismatch repair deficiency and tumour mutational burden, PSA and alkaline phosphatase, Circulating tumour DNA), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include mCRPC, androgen receptor pathway inhibitor-naive, mCRPC after an androgen receptor pathway inhibitor, chemotherapy-naive, mCRPC after taxane chemotherapy.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
First line, androgen receptor pathway inhibitor-naive
- For my situation (first line, androgen receptor pathway inhibitor-naive), which of the standard options do you recommend and why?Guideline options include: Abiraterone or enzalutamide; add olaparib, talazoparib or niraparib for HRR-mutant, above all BRCA-mutant, disease (PROpel, TALAPRO-2, MAGNITUDE).
- Am I a candidate for Abiraterone acetate, Enzalutamide, Olaparib or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PROpel and TALAPRO-2 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
After an androgen receptor pathway inhibitor
- For my situation (after an androgen receptor pathway inhibitor), which of the standard options do you recommend and why?Guideline options include: Docetaxel; olaparib or rucaparib for BRCA-mutant disease (PROfound); 177Lu-PSMA-617 for PSMA-positive disease before chemotherapy (PSMAfore); pembrolizumab for mismatch repair-deficient tumours.
- Am I a candidate for Docetaxel, Olaparib, Rucaparib or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PROfound and PSMAfore apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
After docetaxel
- For my situation (after docetaxel), which of the standard options do you recommend and why?Guideline options include: 177Lu-PSMA-617 (VISION), cabazitaxel, radium-223 for symptomatic bone-only disease (ALSYMPCA), or a PARP inhibitor if not yet used.
- Am I a candidate for Lutetium-177 vipivotide tetraxetan, Cabazitaxel, Radium-223 dichloride, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of VISION and ALSYMPCA apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Bone health
- For my situation (bone health), which of the standard options do you recommend and why?Guideline options include: Denosumab or zoledronic acid to prevent skeletal events, with calcium and vitamin D; palliative radiotherapy to painful metastases.
- Am I a candidate for Denosumab, Zoledronic acid, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Phase 3 options
- For my situation (phase 3 options), which of the standard options do you recommend and why?Guideline options include: Actinium-225 PSMA radioligands, the STEAP1 T-cell engager xaluritamig, the EZH2 inhibitor mevrometostat and 177Lu-PSMA-I&T within trials.
- Am I a candidate for Actinium-225 PSMA agents, Xaluritamig, Mevrometostat or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of AlphaBreak (FPI-2265) & AcTION (225Ac-PSMA-617) and XALute apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Any stage
- Are there clinical trials I could join, for example of Actinium-225 PSMA agents, Xaluritamig, Mevrometostat, 177Lu-PSMA-I&T?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “The best sequence of radioligand, PARP inhibitor and chemotherapy is untested”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Actinium-225 supply and the lack of alpha-emitter dosimetry”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
- MEVPRO-1Phase 3 · active · NCT06551324mCRPC after abiraterone: mevrometostat + enzalutamide vs physician's choice (enzalutamide or docetaxel)
- XALutePhase 3 · active · NCT06691984mCRPC after ARPI and taxane: xaluritamig vs cabazitaxel or second ARPI (investigator's choice; ≥50% cabazitaxel)
- AlphaBreak (FPI-2265) & AcTION (225Ac-PSMA-617)Phase 2 · active · NCT06402331PSMA-positive mCRPC: actinium-225 PSMA radioligands vs standard of care, including after 177Lu-PSMA
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Metastatic castration-resistant prostate cancer: the full pageMetastatic castration-resistant prostate cancer is disease that grows despite castrate testosterone. Sequenced treatments now include androgen receptor inhibitors, docetaxel and cabazitaxel, PARP inhibitors for men with BRCA-type mutations, the radioligand 177Lu-PSMA-617 and radium-223 for bone-predominant disease.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.