We looked at a global study, numerous countries, about 374 patients with non-metastatic hormone-sensitive prostate cancer that would potentially be started on ADT and various ARPIs. Essentially these were patients that would most likely elect to have radiation therapy. So there were some validated questionnaires and trying to understand what were the decisions for patients regarding in terms of a discrete choice experiment, what would be most meaningful to them?

At the top of the list, not surprisingly, was metastasis free survival, so avoiding of spread of their cancer. But then very early on we saw that other things that were really important to patients were hot flash, fatigue, breast-related symptoms and effects of their sexual function.

At the bottom line this study teaches us that when picking an ARPI in addition to an ADT, whether it’s arguably with getting radiation therapy for localised disease or we expand upon it to mHSPC, outfitting and listening to a personalised care plan was really the take home there. This was with some validated instruments looking at patients thinking about balancing one benefit versus another.

So we need to learn from this and recognise that for some patients what’s at the top of their list. Clearly getting good clinical benefit, MFS in this particular discrete choice experiment, but then very soon underneath that issues regarding hot flash, fatigue, loss of sexual function.

How can these results be used in clinical practice?

We have the luxury in certain countries of having more than one choice of different AR pathway inhibitors or androgen biosynthesis inhibitors, drugs particularly such as abiraterone or enzalutamide or apalutamide and darolutamide. That’s in conjunction with testosterone suppression. So I think it's important that our colleagues, whether they’re uro-oncologists, medical oncologists, radiation oncologists, really try to understand what is of greater importance to the patient. And we recognise that there’s a spectrum, whether it’s their exercise tolerability, their fatigue, hot flash versus loss of sexual function.

Some of the things that really weren’t included in this might be the food effects, pill count, drug-drug interaction. We really didn’t query that in great detail but these other factors, I think, are really important. Why is it important? I think it falls under the mantra of shared decision-making, assuming that one has accessibility to all of these, depending upon the country and the regulatory approvals that you have.