OnCo

Prostate cancer: lines of therapy

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11 standard-of-care settings across 5 lines and 4 biomarker subgroups. Rows come from the cancer page's standard of care; the grid places each on its line and subgroup.

LineAll comersCastration-resistantHormone-sensitiveRisk group
Screening, prevention and diagnosis1···
Early / localised1··2
Advanced, first line·22·
Second line11··
Third line and beyond·1··

Screening, prevention and diagnosis

SubgroupSettingApproachProducts and trialsEvidence
All comersScreeningShared-decision PSA testing from 50 (45 if Black or family history/BRCA), risk-adapted intervals; MRI before biopsy; avoid biopsy if MRI negative and PSA density low.76

Early / localised

SubgroupSettingApproachProducts and trialsEvidence
All comersLocalisedActive surveillance, prostatectomy, or radiation ± ADT (duration guided by risk/ArteraAI).40
Risk groupLocalised, low / favourable-intermediate riskActive surveillance (PSA, MRI, repeat biopsy) for Grade Group 1 and many favourable GG2; genomic classifier or ArteraAI to refine.64
Risk groupLocalised, unfavourable-intermediate / high riskRadical prostatectomy (robotic) or radiotherapy (hypofractionated IMRT, SBRT, or brachytherapy boost) with 4-6 months (intermediate) to 18-36 months (high risk) of ADT; abiraterone added for very high risk (STAMPEDE); ArteraAI predicts ADT benefit.95

Advanced, first line

SubgroupSettingApproachProducts and trialsEvidence
Castration-resistantNon-metastatic CRPCApalutamide, enzalutamide, or darolutamide (SPARTAN, PROSPER, ARAMIS); PSMA PET usually reclassifies as metastatic.94
Castration-resistantMetastatic CRPC, first lineARPI (if not used earlier); PARP inhibitor + ARPI for BRCA/HRR-mutant (olaparib-abiraterone, talazoparib-enzalutamide, niraparib-abiraterone); docetaxel; 177Lu-PSMA-617 after one ARPI before chemotherapy (PSMAfore); pembrolizumab if MSI-high.98
Hormone-sensitiveMetastatic hormone-sensitiveADT + ARPI ± docetaxel; PSMA PET staging; capivasertib if PTEN-deficient.95
Hormone-sensitiveMetastatic hormone-sensitive (mAPMN/S)ADT (GnRH agonist/antagonist, e.g., relugolix) + ARPI (abiraterone, enzalutamide, apalutamide, or darolutamide); add docetaxel for high-volume de novo disease (ARASENS, PEACE-1); add 177Lu-PSMA-617 if PSMA-positive (PSMAddition, approved 31 Jul 2026); capivasertib + abiraterone if PTEN-deficient (2026); prostate RT for low-volume disease.96

Second line

SubgroupSettingApproachProducts and trialsEvidence
All comersBiochemical recurrencePSMA PET to localise; salvage radiotherapy ± ADT after prostatectomy; metastasis-directed SBRT for oligorecurrence (investigational for survival); enzalutamide ± ADT for high-risk BCR (EMBARK).94
Castration-resistantCastration-resistantARPI switch, PARP inhibitor combinations (HRR+), 177Lu-PSMA-617, docetaxel/cabazitaxel, radium-223.95

Third line and beyond

SubgroupSettingApproachProducts and trialsEvidence
Castration-resistantMetastatic CRPC, later lines177Lu-PSMA-617 post-taxane (VISION); cabazitaxel (CARD); radium-223 for bone-only symptomatic disease (with bone protection); 225Ac-PSMA, xaluritamig, pasritamig, mevrometostat in trials; platinum-etoposide for neuroendocrine transformation; tarlatamab/I-DXd trials for DLL3/B7-H3.95

Sequence and caution pairings

Regimens in the library

Lines and subgroups are parsed from the setting text of each standard-of-care row and can misclassify an unusual phrasing; the row’s own setting is always shown. Guideline chips reflect the NCCN category and ESMO-MCBS grade recorded on the cancer page, checked on its stated date. Not medical advice.