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Metastatic Castration-Sensitive Prostate Cancer

High-Risk Definition from the LATITUDE study
At least two of the following criteria:
 ≥ 3 bone metastases
 Visceral metastases
 Gleason score ≥ 8

High-Volume Definition from the CHAARTED study
At least one of the following criteria:
 ≥ 4 bone lesions with ≥1 beyond the vertebral bodies and pelvis
 Visceral metastases

Low Vol/Risk Disease High Vol/Risk Disease

Aggressive phenotype
Non-aggressive phenotype
ie. visceral mets, low PSA

ADT
+ Radiotherapy ADT ADT
Apalutamide +/- to the + +
Enzalutamide primary Abiraterone Docetaxel
Abiraterone Apalutamide Abiraterone
Enzalutamide Apalutamide
Docetaxel Enzalutamide

Parker CC, et al. Lancet 2018;392:2353-66
Boeve LMS, et al. Eur Urol 2019;75:410-08 May consider
So et al. CUAJ 2020;14:17-23
Kyriakopoulos CE, et al. J Clin Oncol 2018;36:1080-87 ADT
Sweeney CJ, et al. N Engl J Med 2015;373:737-46 +
James ND, et al. Lancet 2016;387:1163-77 Docetaxel
Fizazi K, et al. N Engl J Med 2017;377:352-60; +
James ND, et al. N Engl J Med 2017;377:338-51 Abiraterone or Darolutamide
Chi KN, et al. N Engl J Med 2019;381:13-24
Davis ID, et al. N Engl J Med 2019;381:121-31 if patient is appropriate for
Armstrong AJ, et al. J Clin Oncol 2019;37:2974-86 triplet therapy
Smith MR, et al. N Engl J Med 2022. doi: 10.1056/NEJMoa2119115.