How do you approach non-metastatic castration-resistant prostate cancer?

The two recent placebo controlled trials comparing apalutamide and enzalutamide in M0CRPC (SPARTAN and PROSPER) have shown sizeable and consistent effects on various outcome measures, clearly met the primary study endpoints and hence satisfied FDA regulatory criteria for drug approval in this space. In my opinion, that does not mean that all patients with M0 CRPC should receive the novel AR targeted drugs. A number of questions remain unanswered from these studies, which in my view are critical: who should be treated, what is the post progression outcome in patients who become M+, are they resistant to subsequent AR targeted treatment? What are the long term toxicities with these drugs?

Adequate patient selection remains unanswered at this t...

Would use older drugs like nilutamide. Better imaging studies in the future may allow us to detect metastases sooner. Drugs like enzalutamide and abiraterone not approved for this indication and maybe challenging to get insurance to approve