Prostate Cancer: The Daily PANCE Blueprint
A 68-year-old man is seen for three months of progressive low back pain that is worse at night and unrelieved by rest. On digital rectal examination there is a hard, irregular nodule in the right posterior lobe of the prostate, and his PSA is 46 ng/mL. Biopsy confirms adenocarcinoma of the prostate, and a bone scan shows widespread osseous metastases in the spine and pelvis. He has an excellent performance status, no neurologic deficits, and no contraindication to systemic therapy. Which of the following is the most appropriate initial systemic therapy?
A. Finasteride
B. Tamsulosin
C. Androgen deprivation therapy alone
D. Radical prostatectomy
E. Androgen deprivation therapy combined with an androgen receptor pathway inhibitor
Answer and topic summary
The answer is E. Androgen deprivation therapy combined with an androgen receptor pathway inhibitor
Metastatic hormone-sensitive prostate cancer is treated with androgen deprivation therapy PLUS an androgen receptor pathway inhibitor — not with ADT alone. This is the part of the answer that has changed, and it is worth updating your mental model: the AUA/SUO guideline now gives a Grade A recommendation to add abiraterone with prednisone, apalutamide, enzalutamide, or darolutamide to ADT in the majority of these patients. Doublet therapy improves overall survival over ADT alone, and selected patients with high-volume disease get a triplet with docetaxel added. ADT remains the backbone — an LHRH agonist such as leuprolide, an LHRH antagonist such as degarelix or oral relugolix, or surgical castration — because prostate adenocarcinoma is androgen-driven and castrate testosterone levels shrink it everywhere at once. One pearl that shows up on exams and matters at the bedside: an LHRH agonist causes an initial testosterone surge, the flare phenomenon, which can worsen bone pain and, with vertebral metastases, precipitate spinal cord compression. Block it with a short course of a first-generation antiandrogen such as bicalutamide started before or with the agonist — that is the one remaining role for those older drugs. LHRH antagonists do not flare. Add bone-protective therapy and calcium and vitamin D. Sorting the distractors: finasteride is a 5-alpha-reductase inhibitor for benign prostatic hyperplasia and has no role in treating established prostate cancer; tamsulosin is an alpha-blocker that relaxes the bladder neck for obstructive urinary symptoms and does nothing to the tumor; ADT alone was the standard for decades and is the trap in this question — it is now reserved for the minority who cannot tolerate intensification; and radical prostatectomy is a treatment for localized disease, not for a cancer already seeded throughout the skeleton.
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