The combination of androgen deprivation therapy (ADT) and androgen receptor pathway inhibitors (ARPI) or docetaxel improves survival for patients with metastatic castration-sensitive prostate cancer (mCSPC). Yet adoption by oncologists and urologists is lagging, with many failing to prescribe treatment intensification in the first-line setting, despite guideline recommendations and even the presence of visceral metastases.

In a retrospective study of 4675 insured patients with mCSPC in the 2014-2019 Optum Research Database, 16% of patients received care from urologists only, 20% from oncologists only, 63% from both specialists, and 1.1% from other providers.

ADT with or without a first-generation nonsteroidal antiandrogen (bicalutamide, flutamide, or nilutamide) was the first-line mCSPC treatment prescribed to nearly 90%, 64%, and 66% of patients treated by urologists only, oncologists only, or both, respectively.

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Guideline-recommended ADT plus ARPI accounted for only 7.4%, 17%, and 15% of first-line mCSPC treatments received by patients treated by urologists only, oncologists only, or both, respectively, Neeraj Agarwal, MD, of Huntsman Cancer Institute, University of Utah in Salt Lake City, and colleagues reported in The Journal of Urology. Among patients seen by both specialists, 78% were prescribed ARPIs by oncologists, 12% by urologists, 0.89% by both, and 9.1% by other clinicians. The odds of first-line treatment with ADT plus ARPI were 3.2- and 3.0-fold higher among oncologists only or both specialists, compared with urologists alone. ARPI included abiraterone, apalutamide, enzalutamide, and darolutamide.

Use of ADT plus docetaxel was 0.91% among urologists only, compared with 14% and 12% among oncologists only or both specialties, respectively.

From 2014 to 2019, use of ADT with or without a nonsteroidal antiandrogen in the first-line setting decreased, use of ADT plus docetaxel stayed stable, and use of ADT plus ARPI increased.

Adequate first-line mCSPC therapy is still lacking, according to Dr Agarwal’s team.

“Barriers to up-front adoption of ARPIs include patient fitness, comorbid illnesses, higher drug costs, and less familiarity relative to ADT [with or without nonsteroidal antiandrogens],” they wrote. “Tolerability and quality of life are also considerations but are unsupported by patient-reported outcomes.”

Urologists treated older men with more comorbidities compared with oncologists, which could have dissuaded them from prescribing intensified first-line therapy, the investigators noted. However, ADT plus ARPI was the most prescribed regimen in the second and third line across all specialties. Both specialists need to increase adoption of ADT plus ARPI in the first line, Dr Agarwal and colleagues noted.

“A better understanding of the reasons for underutilization of [treatment intensification] in mCSPC across specialties warrants further research, including assessment of patient and provider preferences, PSA reduction goals, perceptions about ARPI tolerability, and financial barriers. Insights into these factors may help improve the management of patients with mCSPC.”

In editorial comments accompanying the new report, Stephen J. Freedland, MD, and colleagues from Durham Veterans Affairs Health Care System in North Carolina called the study findings “a wake-up call to the urological community.” They wrote that standard of care treatment intensification should be the norm, not the exception.

Zachary Klaassen, MD, MSc, of the Medical College of Georgia-Augusta University, and colleagues observed: “While further advances are exciting, understanding why most men with mHSPC fail to receive today’s standard of care should be at least as important as looking for the next advance.”

Disclosure: This research was supported by Astellas Pharma Inc and Pfizer Inc. Please see the original reference for a full list of disclosures.


Swami U, Hong A, El-Chaar NN, et al. The role of physician specialty in the underutilization of standard-of-care treatment intensification in patients with metastatic castration-sensitive prostate cancer. J Urol 209(6):1120-1131. doi:10.1097/JU.0000000000003370