Dr Garmezy on Personalizing Treatment Intensification in mHSPC

“We should be talking and counseling our patients about these options that are out there so that they can help participate in that conversation.”

Benjamin Garmezy, MD, associate director of genitourinary cancer research at Sarah Cannon Research Institute and a medical oncologist at SCRI Oncology Partners in discussed the increasingly complex treatment landscape for metastatic hormone-sensitive prostate cancer and factors guiding selection between doublet and triplet approaches.

Androgen deprivation therapy combined with an androgen receptor pathway inhibitor provides an appropriate foundation for many patients, Garmezy explained. However, determining which patients should receive a third agent requires consideration of molecular findings, anticipated benefit, and treatment-related toxicity.

Garmezy highlighted BRCA1/2 mutations as important considerations when evaluating PARP inhibitor–based intensification. He noted that questions remain about the benefit of extending these approaches to patients with other molecular alterations, particularly when balancing efficacy against additional adverse effects. He also discussed how PTEN loss and PSMA expression introduce further considerations for targeted treatment selection.

Overlapping biomarkers can complicate these decisions, a patient may have a BRCA1 mutation, PTEN loss, and PSMA-positive disease, creating several potential avenues for intensification without a clear answer regarding the optimal approach. Garmezy also identifies docetaxel as an established option that remains relevant within this expanding landscape.

He emphasized shared decision-making that incorporates comorbidities, patient preferences, and the toxicities an individual is willing to accept. Preserving quality of life is particularly important when patients are feeling well early in their disease course.

Garmezy concluded that collaboration between urologists and genitourinary medical oncologists is essential as treatment options evolve. However, optimal selection strategies remain unsettled, and clinicians should counsel patients about available approaches and actively involve them in treatment discussions, he added.